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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Stelara 90 mg every four weeks. The records provided for review document that this patient has failed multiple therapies including conventional therapy and high-dose Entyvio, which are recommended for the treatment of ulcerative colitis (Rubin, et al.; Sands, et al.). Subsequently, the patient experienced good results with Stelara every eight weeks, with return of symptoms and a low trough level. The provider has recommended treatment with Stelara every four weeks. Stelara has been demonstrated to be safe and effective in the treatment of ulcerative colitis. Recent studies have demonstrated that Stelara 90 mg every four weeks is safe and well-tolerated for the treatment of inflammatory bowel disease, with recovery of effectiveness in patients with active disease (Kopylov, et al.; Battat, et al.; Khorrami, et al.). One recent study showed that 43% of patients with ulcerative colitis on Stelara required dose escalation, and over 50% of patients with dose escalation achieved corticosteroid-free remission, and long-term improvement in endoscopic inflammation (Dalal, et al.). In this case, the patient has moderate-to-severe ulcerative colitis. The records document that the patient has failed multiple recommended alternatives, has a low Stelara level when dosed every eight weeks, complains of active disease symptoms, and has an elevated fecal calprotectin. As the patient experienced initial improvement on Stelara, but a low Stelara level, dose increase to Stelara 90 mg every four weeks is supported. Continuation of the current dose of  90 mg every eight weeks or a change to another medication may be ineffective and may result in complications. For these reasons, the requested Stelara 90 mg every four weeks is supported as medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication dosage 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for proton beam therapy (PBT) in a high dose of 60 Gy in 28 fractions (CPT 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387). The records provided for review document that this patient presents with a history of a carotid body tumor. The patients provider has recommended treatment with PBT. Currently, there is a lack of meaningful clinical data to support the routine use of PBT in the treatment of patients with head and neck cancers or paragangliomas. Furthermore, there is a paucity of published randomized trials that support the use of PBT over treatment with intensity modulated radiation therapy (IMRT) with photons. Per the National Comprehensive Cancer Network (NCCN) guidelines, carotid body tumors should be treated with photons using radiosurgery or fractionated with IMRT, which are associated with low risk of complications. Baxi and colleagues reported that PBT should further improve the conformality of head and neck irradiation, but there are limited actual clinical data and no phase III studies currently supporting their superiority to IMRT with regard to actual clinical outcomes in patients with head and neck cancer. All told, the requested PBT in a high dose of 60 Gy in 28 fractions (CPT 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, S8030, 77470, 77370, and 77387) 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for glioma removal treatment using stimulated Raman histology (SRH) technique. SRH is a diagnostic pathology technique used to make an intraoperative diagnosis and aid in surgical decision making. Researchers published a prospective cohort study on 21 patients who underwent surgical resection of glioma. The tumor specimens were evaluated by SRH and via standard frozen histopathology and then compared to the gold standard of permanent histopathology. These authors reported no difference in diagnostic accuracy between SRH and frozen evaluations, but the time to diagnosis was significantly shorter for SRH. The authors concluded that SRH may serve as an adjunct to conventional histopathology and expedite intraoperative histopathology. Hollon and colleagues performed a multicenter prospective trial and reported that SRH is a means of delivering expert-level intraoperative diagnosis where neuropathology resources are scarce and improving diagnostic accuracy in resource-rich centers. This patients records document evaluation and treatment involving at least one major medical center, which indicates that a neuropathologist will be available for intraoperative diagnosis. Based on the current peer-reviewed medical literature, the requested glioma removal treatment using SRH technique is not 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 glioma removal treatment using SRH technique is 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 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 reviewer 1 is board certified in neurological surgery and is actively practicing. Physician reviewer 2 is board certified in neurological surgery and is actively practicing. Physician reviewer 3 is board certified in neurological surgery 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 patients parent has requested authorization and coverage for in-home setting for the enrollees authorized physical therapy (two visits per week), occupational therapy (two visits per week), and speech therapy (two visits per week). The records provided for review document that this patient has a history of Down syndrome and aspiration. The patient has been treated with occupational, physical, and speech therapies, with documented progress. The patients current treatment regimen is consistent with the recommendations from the National Down Syndrome Society. The patients provider has recommended in-home therapy services. Currently, the patient is too young to be immunized for COVID-19. Repeated visits out of the home for therapy during the pandemic markedly increase her risk for exposure to infection. Vita and colleagues noted that, Down Syndrome, which is caused by trisomy 21, is characterized by immune dysregulation, anatomical differences in the upper respiratory tract and higher rate of comorbidities. All these risk factors can contribute to more severe clinical presentations of COVID-19 in this population. Similarly, Espinosa reported that the immune dysregulation caused by trisomy 21 in patients with Down syndrome supports additional monitoring and specialized care for this vulnerable population. All told, the requested in-home setting for the patients authorized physical therapy (two visits per week), occupational therapy (two visits per week), and speech therapy (two visits per week) is medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollees parent has requested reimbursement for Genomind Professional PGx Express genetic testing. In the records provided for review, this patient presents with a history of behavioral issues and learning disabilities. The patient underwent evaluation with Genomind Professional PGx Express genetic testing. Researchers stated that, Significant advances have been made in the application of pharmacogenomic testing for the treatment of patients with psychiatric disorders. Over the past decade, a number of studies have evaluated the utility of pharmacogenomic testing in pediatric patients with psychiatric disorders. However, the authors concluded that, more research is needed to understand the contributions of pharmacogenomics testing to the clinical treatment of children and adolescents. At present, there is inadequate evidence to support the use of pharmacogenomics in the clinical care of young patients with psychiatric disorders such as attention-deficit/hyperactivity disorder (ADHD), depression, and anxiety. All told, the Genomind Professional PGx Express genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the Genomind Professional PGx Express genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in pediatrics with subspecialty certifications in clinical genetics and clinical biochemical genetics and is actively practicing. Physician reviewer 2 is board certified in neurodevelopmental disabilities and subspecialty certification in neurology with special qualification in child neurology and is actively practicing. Physician reviewer 3 is board certified in clinical genetics and genomics 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for acute medical inpatient care services. Greenberg noted that determining the cause of a patients shoulder pain is usually a clinical diagnosis based on a thorough history and physical examination. Imaging studies are needed on a limited basis in the setting of trauma, possible glenohumeral arthritis, or when a complete tendon tear is suspected. Therapy is based on pain control and therapeutic exercises. Corey and Comeau noted that cervical radiculopathy is the result of irritation and/or compression of nerve root as it exits the cervical spine. Pain is a common presenting symptom and may be accompanied by motor or sensory deficits. Diagnosis is suggested by history and corresponding physical examination findings and confirmation is achieved with MRI. A multimodal approach to treatment consisting of medications, physical therapy, and/or guided corticosteroid injections and selected nerve blocks may help control nerve root pain. This patient presented to the emergency department on 6/25/21 with complaints of right shoulder and upper back pain that progressively worsened over the last couple of days. The patient was admitted, and he underwent physical examination and diagnostic testing. He was treated with morphine, ondansetron, and dexamethasone. Based on the noted examination findings as well as the diagnostic testing results, there were no indications of a condition that required an inpatient stay. The services rendered could have been provided on an outpatient basis with appropriate follow-up and observation. The patient was noted to be independent with activities of daily living, ambulation, and transfers, without evidence of neurologic progression. For these reasons, the acute medical inpatient care 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 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 hyaluronan (Supartz) injections. Evidence from systematic reviews and randomized controlled trials indicate that although viscosupplementation may relieve knee pain in some patients with osteoarthritis, data has not established which patients will benefit. Guidelines from the American Academy of Orthopedic Surgeons (AAOS) indicate that the data on safety and efficacy of viscosupplementation remain inconclusive. As such, the AAOS does not currently recommend viscosupplementation as routine treatment for osteoarthritis of the knees. Viscosupplementation is reserved for patients with a history of lasting benefit from prior injections and in cases where the remaining options are limited. In this case, there is no history of viscosupplementation in the past. However, the patients treatment options are limited due to cardiovascular issues such as atrial fibrillation and essential hypertension. Furthermore, the patient has a history of elevated blood sugar, which does not support treatment with corticosteroid injections. For these reasons, the requested Hyaluronan (Supartz) injections are medically necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for positron emission tomography (PET) of the whole body. Per the American College of Radiology (ACR) practice guidelines, there is a lack of documentation of biopsy proven primary or metastatic malignancy, indeterminate mass found on other imaging, or any other indications to support the medical necessity of the PET scan. Per the ACR, some indications for PET include staging on presentation for guiding initial treatment strategy in patients with a known malignancy, monitoring  response  to  therapy, restaging in the setting of relapse, or to  localize  the  site  of  primary  tumor  when  metastatic  disease  is the  initial  manifestation  of  malignancy. Additionally, per the ACR guidelines, the records do not report any need to verify and localize occult disease, a need to evaluate an abnormality considered indeterminate by another imaging modality, or an indication to guide treatment goals, biopsy, or radiation therapy. Overall, there is a paucity of large scale studies showing the diagnostic role and efficacy of PET to determine the cause for anemia with hemophagocytosis. Given these findings, the PET of the whole body was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in radiology with subspecialty certification in diagnostic radiology 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 proton beam radiation therapy. The submitted documentation fails to demonstrate the medical necessity of the requested services. There is a lack of strong medical evidence to suggest that treatment with proton therapy is associated with a clinical benefit compared to standard treatment. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Vapiwala and colleagues performed a recent multi-institutional analysis of 1,850 patients with low-risk or intermediate-risk prostate cancer. The authors compared groups receiving hypofractionated radiation proton therapy and intensity modulated radiation therapy with photons. This analysis found no significant difference in gastrointestinal or genitourinary toxicities between the two treatments. Furthermore, it found no difference in disease control between the two modalities. The American Society for Radiation Oncology (ASTRO) notes, The comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. The National Comprehensive Cancer Network guidelines endorse the position statement by ASTRO and state that no clear benefit of proton therapy has been demonstrated over standard treatment with photons and intensity-modulated radiation therapy (IMRT) technique. Therefore, proton beam radiation therapy is not medically necessary for the 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that The patient has requested authorization and coverage for RT300 functional electrical stimulation (FES) therapy system. In this case, the patient sustained a traumatic injury to cervical spinal cord. The mainstay of long-term management for this patient population focuses on surveillance and preventive clinical care related to the respiratory system, pressure injury prevention, neurogenic bowel and bladder management, tone issues, pain and monitoring for complications (Ong, et al.). Health and well-being in this patient population is promoted through optimizing medical care and the encouragement of participation in educational, social, recreational, avocational and vocational activities (Tweedy, et al.). While standard medical care and rehabilitation measures may not resolve a patients neurological impairments due to the underlying spinal cord injury, the requested FES cycle ergometer, has not been demonstrated to provide meaningful benefit for patients with this condition. Current studies reported in the peer-reviewed medical literature have not shown that the RT300 FES improve cardiovascular health, pulmonary health, bony health or other health parameters in a clinically significant manner (Nardone, et al.; Soleyman-Jahi, et al.; Phadke, et al.; Farrow, et al.). The RT300 FES may potentially help to improve or maintain muscle mass in weakened or totally paralyzed limbs, but this provides no significant health or functional benefit and does not obviate the need for pressure relief. All told, the requested RT300 FES therapy system is not medically necessary for treatment of this patient. 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that An enrollee has requested reimbursement for FoundationOne CDx genomic test. This patients records document evaluation with FoundationOne CDx genomic testing due to diagnosis of brain ependymoma. The development of sophisticated genetic and molecular characterization of central nervous system neoplasms has shown that histologically similar neoplasms can be characterized more accurately for prognosis and possibly for response to different therapies. Molecular characterization of primary brain tumors, including ependymomas had a substantial impact on stratification and eligibility in clinical trials for central nervous system neoplasms and is increasingly becoming a part of the standard of care. The NCCN guidelines recommend molecular profiling to identify clinically relevant subtypes to encourage opportunities for clinical trial involvement and already approved targeted agents. Given this support, the FoundationOne CDx genomic test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the FoundationOne CDx genomic test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The 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.