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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Keytruda infusions (pembrolizumab). This patient presents with thyroid cancer, for which the standard of care includes dabrafenib and trametinib based on the presence of a BRAF V600E mutation (Subbiah, et al.). The provider recommended the addition of Keytruda in combination with the BRAF targeted therapy. Keytruda is U.S. Food and Drug Administration (FDA) approved for various tumor indications. The National Comprehensive Cancer Network (NCCN) guidelines support treatment with Keytruda for patients with microsatellite instability-high or mismatch repair deficient cancer. This patient underwent testing to assess for BRAF mutations. However, the patients tumor mutational burden was not quantified or reported. Overall, there is a paucity of prospective randomized controlled trials demonstrating that Keytruda provides substantial improvement over standard available treatment options in this patients clinical scenario (Iyer, et al.). Therefore, the requested Keytruda infusions (pembrolizumab) are not 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 requested Keytruda infusions (pembrolizumab) are 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 subspecialty certifications in medical oncology and hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for varicocele vascular embolization procedure. Findings:  The physician reviewer found that Standard treatment of enlarged painful varicocele entails open surgery, laparoscopy, or embolization. Pain relief is anticipated in 50% of cases with classic symptomatology uncomplicated by prior surgeries. Given this patients prior vasectomy, procedures other than venous embolization place the patient at risk of testicular devascularization. Treatment with embolization is the preferred surgical approach to correct the patients clinically diagnosed varicocele Grade 3. Given this support, the requested varicocele vascular embolization procedure is 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 requested varicocele vascular embolization procedure 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 urology 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 reimbursement for custom foot orthotics ordered and casted on 8/12/20.Orthotics have long been considered standard of care for the treatment of proximal heel pain/plantar fasciitis, as well as peroneal tendinitis. Customized orthotic devices control the foot and keep it in a neutral position, reducing stress and strain to the medial arch, origin of the plantar fascia at the heel, as well as peroneal tendons. Historically, custom orthotics are more supportive and can be more controlling to help alleviate heel pain, arch pain, and peroneal tendon pain. Customized orthotics, besides fitting better, are usually fabricated with a firmer functional material to provide superior support and control. In this case, the patient states that he has failed treatment with over-the-counter orthotics. The submitted documentation also shows that the patient has tried and failed low dye foot strapping. Therefore, the custom foot orthotics ordered and casted on 8/12/20 were medically necessary for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is 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: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient has a history of osteoarthritis of both knees. The submitted documentation shows a history of excellent benefit from prior viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being bilateral total knee arthroplasties. Therefore, Orthovisc injection series in both knees 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 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 patient has requested authorization and coverage for surgery to remove the benign seborrheic keratosis, on the right side of face. Seborrheic keratosis is a benign growth that can occur on the skin that may become inflamed when ruptured, especially with trauma, leading to superinfection, pain and itching. In this clinical setting, given that the patient reports a seborrheic keratosis that bleeds when shaved or scratched, the requested service is medically indicated. Therefore, surgery to remove the benign seborrheic keratosis, on the right side of face is medically necessary for the treatment of this patient.The California reconstructive surgery statute requires health insurers to cover reconstructive surgeries, defined as surgery performed to correct or repair abnormal structures of the body caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease to do either of the following: (1) to improve function; or (2) to create a normal appearance, to the extent possible. In this case, the benign seborrheic keratosis is an abnormal structure of the body. The tumor, or seborrheic keratosis, is a benign growth that can occur on the skin. The requested service will improve function and prevent further inflammation, bleeding and pain. Accordingly, the requested surgery to remove the benign seborrheic keratosis, on the right side of face is reconstructive in nature for treatment of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for placement of a mometasone furoate sinus implant (J7401). Peer-reviewed evidence supports the use of mometasone furoate sinus implants for the treatment of chronic rhinosinusitis (CRS) with nasal polyposis. In a systematic review of drug-eluting implants used in the treatment of chronic rhinosinusitis (CRS), Smith and colleagues recommended absorbable steroid-eluting implants for carefully selected patients with CRS. In a randomized clinical trial, Luong and colleagues reported that compared to the non-implanted side at day 90, the side treated with a bioabsorbable mometasone furoate sinus implant demonstrated a significant reduction in the need for postoperative intervention, inflammation, and restenosis of the frontal sinus. Kern and colleagues conducted a randomized, sham-controlled trial of bioabsorbable mometasone furoate sinus implants in 300 patients with refractory CRS who were candidates for repeat surgery and found that those receiving implants had significant reductions in nasal obstruction and severity of polyposis, and a 61% reduction in the need for repeat sinus surgery at day 90. In this case, the patient presented to his provider with a history of nasal congestion, rhinorrhea, facial pressure, and headaches. He had undergone two prior surgical procedures for treatment of nasal polyps. Despite medication therapy, visit notes reported persistent nasal polyps. Given the refractory nature of this patients nasal polyps, several studies support the use of a mometasone furoate sinus implant in this clinical setting. Therefore, the mometasone furoate sinus implant (J7401) at issue was likely to have been more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the placement of a mometasone furoate sinus implant (J7401) at issue was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was likely to have been 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 and 3 are board certified in board certified in otolaryngology and are actively practicing. Physician reviewer 2 is board certified in otolaryngology with sub-specialty certification in sleep medicine and is actively practicing The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a chest computed tomography (CT) scan. Findings: The natural progression of ground-glass nodules is highly variable, ranging from self-resolving inflammatory processes to pre-malignant lesions resulting in adenocarcinoma. While there are no clear guidelines on how to best monitor existing pulmonary nodules, providers generally perform risk-stratification on patients with existing subsolid pulmonary nodules to help in guiding a CT surveillance program. In this case, the patient is a former smoker who presents with multiple, persistent ground-glass pulmonary nodules. The provider recommends low-dose chest CT for ongoing surveillance at the five-year interval. Given this patients risk factors, including significant smoking history, interval stability and persistence of the nodules, the ground-glass appearance of the nodules, and upper lobe location of two of the nodules in question, the requested service is medically indicated. Therefore, a chest CT scan is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certifications in pulmonary disease and  critical care 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for wheelchair accessories (deluxe canopy (K0108) and under seat storage basket (K0108) for the patients already approved pediatric wheelchair).At issue is whether the requested wheelchair accessories (deluxe canopy (K0108) and under seat storage basket (K0108) for the patients already approved pediatric wheelchair) are medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Seating mobility devices are indicated for children who have limited ambulation. In this case, this patient has no structural musculoskeletal impairment or severe functional deficit that would limit his dynamic weight shifting in his current device. His position can be actively and passively changed to accommodate environmental factors. He does not have fixed deformities or pain to prevent this accommodation. Furthermore, these devices are not necessary for safe transportation. Current quality evidence does not support the use of the canopy and under storage basket in this case since they are not medically necessary to treat the patients condition for any of the following: to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; to correct or ameliorate any physical or behavioral conditions.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with subspecialty certification in pediatric rehabilitation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for physical therapy. Findings:  The physician reviewer found that  in this case has experienced chronic, persistent symptoms following remote head traumas. She has undergone vestibular rehabilitation without objective clinical benefit in the past and more recently with some subjective benefit reported. Based on the records provided for review, the patient has undergone sufficient rehabilitation to be independent with a home exercise and self-management program to further improve her balance, endurance, and activity tolerance. The provider noted that the patient is able to exercise on her own without difficulty, and she is participating in a yoga program focused on a history of brain injury. While she has ongoing symptoms, there is no reasonable expectation that additional physical therapy will result in any significant, sustained benefit with respect to health or functional outcomes over an independent program. Most patients recover from concussions within a short interval. Persistence of symptoms beyond the generally accepted time frame for recovery is referred to as post-concussion syndrome (Leddy, et al.). The mainstays of treatment for concussion and post-concussion syndrome are an appropriate period of rest, gradual return to activities, and self-management strategies. Some rehabilitation interventions in the early setting have been shown to be effective in addressing functional concerns, but the effectiveness of rehabilitation measures, including long-term individualized rehabilitation for post-concussion syndrome, are not possible based on the available peer-reviewed medical literature. The evidence base related to the effectiveness of vestibular rehabilitation for post-concussive dizziness is limited and precludes conclusions to support its efficacy. Given these findings, the requested physical therapy is not medically necessary for treatment of this patient. 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 physical medicine and rehabilitation 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 reimbursement for fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts. Findings:  The physician reviewer found that Kearon and colleagues report that when antiphospholipid antibodies are assayed, they may antibodies directed at phospholipid epitopes, which may be useful for the evaluation of patients with a strong clinical suspicion for antiphospholipid syndrome (APS) who have tested negative using other tests for APS. The records submitted for review provide insufficient clinical suspicion of APS or of exocrine pancreatic insufficiency (EPI) for a quantitative fecal fat analysis to be appropriate. In this case, the services at issue were not standard of care and did not provide additional benefits over a standard evaluation of the patients symptoms related to irritable bowel syndrome including a complete blood count, celiac disease serology, stool testing for giardia, and testing for fecal calprotectin. Therefore, fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts was not likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the fecal laboratory testing (CPT 82710 and 83520) provided by Quest Diagnostics Massachusetts at issue was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the service at issue was not likely to have been 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for nasal revision surgery proposed by the provider. Findings:  The physician reviewer found that records provided for review document that this patient has a history of previous nasal operations as well as previous trauma. On physical examination, the provider noted that the patients nasal airway shows some narrowing and there is evidence of an external deviation. The provider has recommended revision surgery. However, with each subsequent surgery, the patients risk of failure is elevated due to an increase in scarring (Howard and Clark; Kocak and Duzenli). Given the patients presentation and prior surgical history, the risks of a revisional surgical procedure outweigh the potential benefits. All told, the revision surgery proposed by the provider is not medically necessary for treatment of this patient.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 otolaryngology 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.