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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested growth hormones (Nutropin AQ NuSpin)for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Although the patients height is more than two standard deviations below the mean for age and gender, his growth factors are normal, and his bone age predicts an adult height that is within normal limits.  He is not known to have a morphological abnormality of his pituitary gland.  He does not have evidence of growth hormone deficiency, and his adult predicted height is not short enough to warrant growth hormone treatment on the basis of idiopathic short stature according to U.S. Food and Drug Administration (FDA) criteria. The most likely cause of his growth fall-off is delay in pubertal development, which may have been exacerbated by underlying attention deficit/hyperactivity disorder and treatment medication.  All told, the requested growth hormones (Nutropin AQ NuSpin) are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Botox for treatment of the enrollees hyperhidrosis. Findings: The physician reviewer found that the patient has tried and has reportedly failed Drysol, and has had a significant impact as a result of her hyperhidrosis. The condition of hyperhidrosis is known to be socially disabling, and can be very disruptive. Management strategies in the literature include oral medications, topicals such as Drysol, and Botox.  The use of oral medications is not supported by robust evidence.  In addition, side effects such as fatigue or sedation are not uncommon.  On the other hand, Botox is well studied for hyperhidrosis, with an FDA indication for this purpose.  Data supports high effectiveness with low side effects. A recent study of treatment in adolescents notes that when using quality of life measures, health outcomes improved markedly. In sum, Botox is medically necessary in the treatment of the patients medical condition.   Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a water circulating cold pad with pump for treatment of her medical condition.  Findings:  Two physician reviewers found that a water circulating cold pad with pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of high quality evidence that demonstrates that the use of active cooling devices results in better outcomes over the use of topical ice pack application. According to Hubbard and Denegar Many more high-quality studies are required to create evidence-based guidelines on the use of cryotherapy. These must focus on developing modes, durations, and frequencies of ice application that will optimize outcomes after injury. All told, a water circulating cold pad with pump was not likely to be more beneficial for the treatment of the patients medical condition than the available standard therapy.  Final Result: Two reviewers determined that the equipment at issue was 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 reviewers are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. This has been shown to be most useful in the evaluation of the dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. All told,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any other available standard therapy.  Final Result: Three 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:  All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Xyrem for treatment of her medical condition. Findings: Three physician reviewers found that the medical evidence does not support the requested medication in this clinical setting.  Xyrem may be appropriate for the treatment of narcolepsy and the auxiliary symptoms of cataplexy, sleep paralysis, hypnagogic hallucinations, and automatic behavior.  Per the medical records, this patient does not have these symptoms.  Concurrent use of Xyrem with other central nervous system depressants, such as the multiple medications the patient is already taking, causes increased risk of respiratory depression, hypotension, profound sedation, syncope, and death.  The drug has been studied in patients with a diagnosis of narcolepsy. There is no demonstrated utility or safety for the use of this drug for patients without this diagnosis.  Therefore, the superior benefit of the requested medication has not been established.  Final Result: Three 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: All three reviewers are board certified in internal medicine 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography (PET) scan for evaluation of his medical condition. Findings: Two physician reviewers found that although a PET scan is not indicated for every patient with progressive cognitive symptoms, it is useful and beneficial for a subset of patients who are suspected to have front temporal dementia versus Alzheimers disease versus a personality disorder.  In this case, the patient had progressive cognitive decline at a young age with abnormal psychometric testing and no other clear imaging abnormality or serum abnormality to provide a diagnosis.  In cases such as this one, it is essential to obtain the correct diagnosis to implement the proper treatment, and avoid unnecessary treatments that may produce significant side effects. In this clinical setting, a PET scan was a reasonable medical approach to determine his diagnosis and implement the proper therapy.  Therefore, the PET scan performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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: All three physician reviewers are board certified in neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested ranibizumab injections for treatment of her medical condition. Findings: Two physician reviewers found that ranibizumab injections were not and are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Best disease is a hereditary condition that causes degeneration of the central retina. Best disease may be accompanied by choroidal neovascularization (CNV) in 20% of patients.   While there is no treatment for Best disease, there is treatment for the accompanying CNV, should it occur.  The standard of care for treatment of CNV is anti-vascular endothelial growth factor agents, such as Lucentis. However, in this case there is no documentation provided to indicate that CNV is present.  Final Result: Two reviewers determined that the services at issue were not and 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 ophthalmology 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:   An enrollee has requested an in-home light therapy for treatment of her dyshidrotic eczema. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested in-home device. Generally, (UVB) light phototherapy is administered in an outpatient clinic two or three times per week.  The patient is seeking coverage for an in-home light unit because it is difficult for her to attend office-based phototherapy given her work schedule. There is no documentation of any medically-based barriers to in-office treatment. Nor is there evidence that the patient is physically limited in her capacity to seek office-based treatment. All told, the requested in-home unit is for purposes of convenience and is not clinically indicated. In sum, the in-home light therapy unit is not medically necessary for the treatment of this patients medical condition.  Final Result: The reviewer determined that the requested device 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 a Mobi-C two-level cervical total disc replacement procedure for treatment of her medical condition.  Findings:  Three physician reviewers found that upon review of the submitted documentation there is inadequate support for two-level cervical disc replacement (arthroplasty) in this case. There are alternative approaches that are likely to avoid potential complications of re-operation and would avoid the potential complications of double-level cervical total disc arthroplasty. In a study by researchers, pooled data from multiple sources were analyzed with an incidence of heterotopic ossification of 44.6% at 12 months after total disc arthroplasty and 58.2% at 24 months. The authors concluding that cervical total disc arthroplasty should be performed cautiously. In an article other researchers, the authors pointed out that in most of the studies they reviewed there is a tendency for a more postoperative kyphotic alignment after total disc arthroplasty. Total disc arthroplasty has been recommended for this patient for the prevention of adjacent segment disorder through preservation of motion. However, it remains controversial whether motion at the replaced intervertebral disc will in fact be maintained over time and there is evidence that there is a gradual loss of motion by reason of a number of factors. The most important of these factors include myositis ossificans, fibrous tissue and bone or an inflammatory response to wear and to the trauma of surgery, which involves the formation of both.   In summary, there is insufficient evidence that the proposed two-level Mobi-C cervical total disc replacement is likely to result in a superior clinical outcome for this patient. Thus, the requested services are not 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 services 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 reviewers are board certified in orthopedic surgery 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: An enrollee has requested partial hospitalization program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient attested to suicidal thoughts without intent or plan.  The homicidal thoughts noted in the summary do not constitute true homicidal ideation, in that the patient inappropriately seemingly verbalizes all that she is thinking.  She did not suffer from grave disability.  Family therapy was occurring, and her parents were receiving education.  She was medically stable and compliant.  No new problems had arisen.  Exposure had begun, the patient had improved, and her ability to be in public had increased.  All told, partial hospitalization program services were not and are not medically indicated for the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has  requested spinal epidural injections for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for spinal epidural injections has not been established. According to the documentation, the patient has imaging that is not consistent with radiculopathy. Additionally, the physical exam was not consistent with radicular pain. The peer-reviewed literature supports the utilization of epidural steroid injections in patients with confirmed radiculitis by MRI and physical exam. It is not appropriate to continue treatment with epidural steroid injections in this case where there is lack of documentation to corroborated lumbar radiculopathy. In addition, researchers evaluated the effectiveness of injection therapy for low-back pain.  The literature concluded that there is no strong evidence to support use of injection therapy for non-radicular low-back pain. Given the above, the requested services are not medically necessary for treatment of the patients medical condition.  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 anesthesiology with sub-certification in pain 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 the medication combination Yervoy (ipilimumab) 300 mg and Opdivo (nivolumab) 92 mg, for three weeks, refills for one year, nine cycles for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that Opdivo, Yervoy, and Keytruda are new monoclonal antibodies that bind with tumor antigens responsible for blocking immune attack from circulating lymphocytes.  The current U.S. Food and drug Administration (FDA) label for Opdivo does not state that prior treatment with Keytruda is a contraindication.  Progressive disease on Keytruda can be treated with Yervoy and Opdivo combination therapy if it has not been used before. The combination therapy is supported by the medical literature where certain patients were treated with the combination after monotherapy. That is the situation presented by this case.  Thus, there is support for the combination of Yervoy/Opdivo in this clinical setting.  The medical literature supports continued use of the medication combination every 12 weeks.  However, there is a lack of support for the requested dosing of this medication.  Final Result: Two reviewers determined that a portion of the requested medications 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 partially overturned.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: An enrollee has requested Nucynta for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient has undergone multiple injections and spinal surgeries. In a letter, the provider reported that the patient has tried and failed multiple opioid and non-opioid analgesics and multimodal regimen including physical therapy, psychotherapy and interventional procedures.  She would not be taking multiple long-acting opioids together, but would be utilizing Nucynta in place of methadone secondary to intolerable side effects.  A trial of Nucynta is reasonable based on the documentation submitted for review.  All told, Nucynta is medically indicated for the 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 sub-specialty certification in pain 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: An enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings:  The physician reviewer found that per the American Society of Addiction Medicine (ASAM) criteria, residential treatment center services were not medically necessary for this patient as her acuity level was not sufficiently high in each dimension. The submitted documentation demonstrates that the patient was not at risk of severe withdrawal and she was not a danger to self or others. The patient had symptoms of withdrawal which were mild in nature. Per the records, she was medically and psychiatrically stable; she was not psychotic or manic; and she was cognitively capable of participating in a program. As such, a residential level of care was not required for management of the patients condition. The progress notes indicate that she was cooperative and she participated in her treatment plan.  In sum, residential treatment center services were not medically necessary for treatment of the patients medical condition.  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..