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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for lidocaine 5% patch. The submitted documentation does not support the medical necessity of the requested medication. Lidoderm 5% patches have been studied in randomized controlled trials, and it has not been found to be better than placebo. Thus, the medical evidence does not indicate that the requested medication is clinically effective for low back pain. There is a lack of support for the requested medication in this clinical setting. Therefore, lidocaine 5% patch is not medically necessary for 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for EsophyX Transoral Incisionless Fundoplication (TIF). Findings:  Three physician reviewers found that appropriate patient selection is crucial before anti-reflux procedures. The treating provider has recommended a TIF procedure. The technique has shown merit and durable response in selected GERD patients. However, this patient cannot be considered medically refractory, since she has opted for herbal supplementation in lieu of proton pump inhibitor therapy. Available records do not support contraindication to proton pump use. The records do not document that the patient has recently maximized available medical management. Per the literature, the patient is not likely benefit to a greater extent from TIF than from optimized acid suppression therapy, and there is significant risk for surgical complications of the proposed anti-reflux procedure. Accordingly, the requested services are not likely to be of greater benefit than other treatment options. Final Result: The 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection for treatment of the enrollees knee pain.  Findings:  The physician reviewer found that there is sufficient support for the requested service in this clinical setting. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis. She reported good results with a Synvisc One injection that lasted for approximately six months, with return of symptoms. Her prior conservative treatment has included physical therapy, rest, nonsteroidal anti-inflammatory drugs, bracing, and corticosteroid injections, with inadequate relief. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Given the previous response and to assist in delaying total knee replacement for this patient, repeat Synvisc One injection is indicated. Therefore, the requested Synvisc One injection is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for H.P. Acthar. The patient reportedly has failed treatment with methotrexate, IVIG, Orencia, prednisone, azathioprine and CellCept.  Although there is literature to show possible efficacy of Acthar in refractory myositis, these studies are small.  There is a lack of randomized controlled trials demonstrating the efficacy of Acthar for the treatment of refractory myositis. The current literature supports the use of rituximab in such cases of resistant myositis. Rituximab has the most literature to support its efficacy and safety and is the preferred agent due to evidence demonstrating improvement in symptoms, reduction in dependence or oral steroids and safety. The medical records fail to demonstrate a trial of rituximab or a contraindication to it. As such, H.P. Acthar gel is not medically necessary.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a nine-year-old male enrollee has requested authorization and coverage for one hour individual speech therapy sessions once per week. The requested one hour individual speech therapy sessions once per week is medically necessary for treatment of the patients medical condition. The records indicate that the patient has a duplication at chromosome 22q11.2, a condition well recognized as resulting in significant speech and language impairment. In addition to cognitive impairment in chromosome 22q11.2 duplication, studies noted that one of the prevalent and serious problems encountered by patients with the 22q11.2 deletion is difficulty with speech. This may be due to a number of factors such as adenoid hypoplasia, muscle hypotonia, platybasia, upper airway asymmetry, and neuroanatomical abnormalities. This patient has made significant progress in speech therapy, with improvement in his apraxia of speech. However, his speech is still only 75% intelligible, which will lead to difficulty in social interaction with his peers, and may contribute to behavioral and psychological disorders if untreated. Given these findings, the requested one hour individual speech therapy sessions once per week is supported as medically necessary for treatment of this patients medical condition. 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 pediatrics and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollee who has a history of metastatic lung cancer.Findings:  The therapy for advanced non-small cell adenocarcinoma has been revolutionized by the finding of EGFR mutations in adenocarcinomas, especially in this patient who is a non-smoker. The medical literature indicates that even if stage IV disease is present, therapy targeted to EGFR with erlotinib results in prolonged survival when compared with standard chemotherapy regimens. The mutational landscape of non-small cell lung cancer (NSCLC) has significantly expanded in the past two to three years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. Generally, KRAS, TP53, and BRAF are included in these panels and are informative. KRAS and EGFR mutations are usually mutually exclusive so a sample with KRAS mutation does not need to be further analyzed for EGFR mutation. KRAS mutation may confer a poor prognosis on patients with wild type EGFR sequence treated with erlotinib as second line therapy. In this case, the patients tumor tested negative for this panel. Patients on targeted therapy do develop resistance to erlotinib and this too may be appreciated at the genetic level by recognition of new mutations or amplifications in parallel signal transduction pathways. BRAF mutations may suggest alternative targeted therapies that may be better than those selected empirically. Accordingly, current medical evidence supports the superior efficacy of the services at issue in this patients case. For these reasons, FoundationOne testing was likely to have been more effective than the standard methods for evaluating this patients medical condition.Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for panniculectomy. Findings:  The physician reviewer found that based on the available documentation, the requested panniculectomy is not medically necessary for treatment of this patients excess abdominal skin. The medical records do not provide any documentation from the patients providers that describe ongoing clinically significant dermatologic problems that have either never responded to physician directed topical therapy or despite initial response, have recurred and caused significant functional impairment. Overall, supervised medical management for rashes is not documented in any of the progress notes. Moreover, the patient has not reportedly had any ulcerations, panniculitis or sepsis from her infections. Physician supervised treatment is the simplest and safest method of managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In addition, the requested panniculectomy is not reconstructive in nature. The patients condition does constitutes an abnormal structure of the body caused as a result of weight loss surgery in treating the patients obesity. However, the requested surgery has not been requested to improve function, and will not create a more than minimal improvement in the patients appearance. Therefore, conservative, non-operative treatment is recommended such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy is reserved for patients who have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. For these reasons, the requested panniculectomy is not medically necessary and is not reconstructive in nature for treatment of this patients excess abdominal skin. Final Result: The reviewer determined that the requested surgery is not medically necessary and is not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for ketamine assisted psychotherapy services. Findings:  Three physician reviewers found etamine is a dissociative drug commonly used as an anesthetic in veterinary practice. Ketamine is not approved by the United States Food and Drug Administration (FDA) for treatment of psychiatric illness, but its off-label use is becoming more common. The duration of action of ketamine is rather brief, while the poor bioavailability of oral ketamine has prompted the use of intramuscular, intravenous and intranasal delivery systems.  In addition to the difficulty delivering the medication, the lack of adequately-powered, long-term studies raises potential concern regarding the safety, addictiveness and longstanding effects of ketamine therapy. Further, the medical records do not demonstrate treatment refractoriness or the exhaustion of standard therapies available to treat the patients condition. In sum, ketamine assisted psychotherapy services were not and are not likely to be of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a third opinion consultation with a plastic surgeon. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollees medical condition. Findings: There is support in the documentation provided for the medical necessity of the requested services in this clinical setting. The initial consultation with a plastic surgeon proposed a different treatment plan from the second plastic surgeon. The first surgeon suggested a staged approach with mastopexy followed by augmentation mammaplasty. The second plastic surgeon recommended an apparent single stage procedure, as well as other surgical options. The patient was not comfortable with the recommendation proposed by the second plastic surgeon who suggested a possible liposuction. The second consultation occurred after the patient had significant weight loss. Accordingly, the patients current request should be considered a second opinion following the 2017 plastic surgeon consultation. Moreover, the patients medical condition is a complex condition that requires possible complex breast reconstruction. Thus, an additional plastic surgery consultation should be considered medically necessary to re-evaluate the patient and provide an expert opinion. For these reasons, the request for a third opinion consultation with a plastic surgeon has been demonstrated as medically necessary in evaluating this patients medical condition.Final Result: The reviewer determined that the requested services are 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 plastic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee requested authorization and coverage for insertion of a spinal stabilization device, Coflex. The peer-reviewed literature has several studies that support the use of interspinous fixation as an adjunct to decompression in patients with lumbar spinal stenosis and Grade I spondylolisthesis. Davis and colleagues demonstrated in a high quality randomized multicenter study that low-grade spondylolisthesis was effectively stabilized by Coflex. In this case, the patient has evidence of spinal stenosis at the L4-5 level with Grade I spondylolisthesis. Therefore, the insertion of a spinal stabilization device, Coflex, is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the insertion of a spinal stabilization device, Coflex, is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. One Reviewer is board certified in orthopedic surgery and is actively practicing.  One Reviewer is board certified in orthopedic surgery and is 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 authorization and coverage for upper airway stimulation device (outpatient surgery). Continuous positive airway pressure (CPAP) has demonstrated excellent efficacy for treatment of OSA. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. Researchers found that hypoglossal nerve stimulation can provide significant improvements in objective and subjective measurements of the severity of OSA. Given this patients BMI of 26, AHI of 20.6, nonconcentric airway collapse, and failure of CPAP, the requested upper airway stimulation device (outpatient surgery) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested upper airway stimulation device (outpatient surgery) 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 upper airway stimulation device (outpatient surgery) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Remicade intravenous infusion. The Health Plan has denied this request indicating that the medication at issue was considered investigational for treatment of the enrollees ulcerative colitis. Findings:  There is support in the medical literature for the medication at issue in this clinical setting. Until recently, the main goals in the treatment of UC were to temper the symptoms, such as diarrhea, pain, and weight loss, by using mesalazine and steroids. With newer medications, such as immunomodulators (thiopurines) and the biologics-providing blockade of tumor necrosis factor (TNF), the goals of the therapy in UC have changed to long-term remission and mucosal healing. The first available anti-TNF therapy in UC included infusion therapy with infliximab every few weeks.  The studies have shown that the anti-tumor necrosis factor- agents infliximab and adalimumab have been used in large-scale clinical trials and are currently widely used in the treatment of inflammatory bowel disease patients, such as in this patient Moreover, the studies have also shown that,   early treatment of Crohns disease with immunomodulators and anti-TNF agents leads to a superior clinical outcome, including healing of the mucosa, compared with standard therapy alone. Accordingly, based on the medical literature, the medication at issue was likely to have been more effective than the available standard therapy for treatment of this patients medical condition.Final Result: Two of the three reviewers have determined that the medication at issue was 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.