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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cosentyx. Findings:  The physician reviewer found that a review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. In this case, the patient has chronic plaque psoriasis and has failed many standard therapies. The Health Plans recommendation for treatment failure of Humira and Enbrel is medically reasonable and appropriate in this clinical setting. Although Cosentyx is a well-established treatment, Humira and Enbrel have also been demonstrated to be safe and effective for patients with plaque psoriasis. Given the lack of treatment failure with Humira and Enbrel, the request for Cosentyx has not been established as medically necessary for treatment of the patients chronic plaque psoriasis.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for eating disorder residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation provided, the patient could have been treated at a less restrictive environment. The patient was medically stable. The patient was at 87% of ideal body weight. The standard of care is to treat patients in the least restrictive environment possible. She did not require 24 hour observation for any medical problems. The patient did not have any suicidal or homicidal ideation. The patient was motivated for treatment. The patient did not have any psychosis, hallucinations, or paranoia that would have required 24 hour observation. The medical literature shows that residential treatment centers do not provide advantages over outpatient management supports. In this case, given that the patient was not medically compromised, the patient could have been treated in a less restrictive environment. For these reasons, eating disorder residential treatment center services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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 VESIcare 10 mg for treatment of the enrollees urinary urgency. Findings:  The physician reviewer found that there is sufficient support in the medical literature and in the documentation provided for the requested medication in this clinical setting. Treatment of this patients condition with VESIcare was not approved on the basis that the patient had not tried and failed the formulary alternatives. However, the records show that this patient has trialed and failed multiple medications. Instead, this patient had responded to treatment with VESIcare. It is not unusual for patients who have been diagnosed with interstitial cystitis and refractory irritative urinary symptoms to fail multimodal therapy. 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 urology 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 six (6) acupuncture sessions for treatment of the enrollees elbow pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. The use of acupuncture for the treatment of epicondylitis is supported in the peer-reviewed literature. Several trials have evaluated the effect of acupuncture on epicondylitis, and report better short-term global outcomes with greater pain relief. A systematic review determined, with good evidence, that a number of treatments, including acupuncture showed positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. Given the support in the peer-reviewed literature, six (6) sessions of acupuncture are supported as medically necessary for treatment of the 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 oriental 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fertility preservation services for treatment of the enrollees risk for iatrogenic infertility secondary to breast cancer treatment. Findings:  The physician reviewer found that female patients undergoing chemotherapy, surgery and/or radiation treatment for cancer may experience serious gonadotoxicity. The extent of ovarian damage is dependent on the type of treatment as well as the age at the time of treatment. As the treatments for malignancies in females continue to improve their survival rates, increasing numbers of patients may seek preservation of their fertility. Reducing the radiation dose to the ovary by shielding or surgically removing the ovaries from the field of radiation may preserve ovarian function. When patients can delay treatment, embryo and oocyte cryopreservation, utilizing in vitro fertilization techniques, can be offered and are now considered the standard of care. Ovarian stimulation with retrieval and cryopreservation of oocytes and embryos can be performed, with later transfer of embryos to the patient or gestational carrier. If damage to reproductive organs from treatment is likely, cryopreserving gametes, embryos, or gonadal tissue may help to preserve fertility. In addition, in vitro fertilization (IVF) techniques for freezing embryos are well established. The American Society for Reproductive Medicine noted that the most established strategy for preservation of female fertility is for a woman to undergo a cycle of IVF and create embryos for later useEstablished methods of fertility preservation include sperm cryopreservation in men and embryo and oocyte cryopreservation in women. Oocyte cryopreservation for the preservation of fertility in patients undergoing chemotherapy for breast cancer, as in this patient, is within the standard of care. Given that the patient is at risk for iatrogenic infertility due to breast cancer, the fertility preservation services were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone HCl tablets for treatment of the enrollees pain.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. There is no clear indication for the use of chronic opiate therapy in this patients case. There is no documentation of a current opiate maintenance agreement, urine toxicology testing or description of therapeutic goals. There is no formal risk assessment other than a statement that her Arizona prescription monitoring program showed no problems. The Centers for Disease Control and Prevention clinical practice guidelines for prescribing opiates do not support the requested medication in this clinical setting. A study noted that there is little evidence to support long-term opiate therapy for low back pain. The current medical evidence does not support the requested medication in this patients case. All told, the requested oxycodone HCl tablets are not medically necessary 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test performed Findings:  The physician reviewer found that there is currently insufficient medical evidence to support the effectiveness of Prometheus Anser VDZ testing compared with conventional courses of action in the management ulcerative colitis. The published studies regarding the use of anti-Entyvio antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-Entyvio antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the antibodies can be transient .  Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, there is insufficient evidence from controlled studies to definitively demonstrate that the blood test performed was likely to be more beneficial for evaluation of the patients ulcerative colitis than any available standard therapy.Final Result: All three of the reviewers determined that the testing at issue was 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 reviewers 1, 2 & 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 reimbursement for the residential treatment center (RTC) services provided, partial hospitalization program (PHP) level of care provided, and intensive outpatient program (IOP). Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, the records provided for review do not support the medical necessity of the residential treatment center (RTC), partial hospitalization program (PHP) and intensive outpatient program (IOP) levels of care services provided to this patient during the period under review. The patient had reported symptoms of nausea, vomiting, headaches, and a sensation of cloudiness. However, there was no evidence of suicidality or homicidality, he did not appear to be manic, psychotic, or delusional, and he was medically and psychiatrically stable. Based on the blood pressure readings provided, his hypertension did not require RTC or PHP level of care for management. The records do not specify whether the patient was engaged in the processes related to his substance abuse, or if he made progress in the 12 step programs. These brief notes documented his levels of anxiety and depression, which were highly correlated to interactions he had with his parents and girlfriend. Throughout all levels of care, the patient slept at least five to six hours a night and ate two to three meals per day. He had episodic nightmares and drug dreams, and endorsed cravings. Overall, it is unclear what progress he had made on a relapse prevention plan, developing coping mechanisms, or learning to identify triggers. The patient did not require the structure and supervision provided in the restrictive RTC setting. The patient could have safely and effectively been treated in a less restrictive treatment setting. All told, the RTC services, PHP level of care, and IOP services were not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 reimbursement for the cervical/thoracic facet joint block for treatment of the enrollees cervical facet spondylosis.  Findings:  The physician reviewer found that based on the documentation submitted for review, cervical/thoracic facet joint block provided has not been established as medically necessary for treatment of the patients medical condition. Researchers support injections as an intervention for neck pain. However, the Health Plans recommendation for failure of conservative non-operative therapy management for a minimum of six weeks in the last six months prior to facet injections is medically reasonable and appropriate in this clinical setting. In this case the records do not show that the patient has failed to respond to conservative non-operative therapy management for a minimum of six weeks prior to facet injections. The patient presented with a two-week history of pain and underwent cervical/thoracic facet joint block. As such, the record does not demonstrate failure of conservative non-operative therapy of six weeks. Final Result: The reviewer determined that the service at issue was 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for left ear cochlear device and implantation with or without mastoidectomy for treatment of the enrollees bilateral sensorineural hearing loss. Findings:  The physician reviewer found that cochlear device implantation (CDI) is well established, and CDI can now be considered the standard of care for patients with severe to profound sensorineural hearing loss and no meaningful benefit from conventional amplification. However, many patients with severe to profound high frequency hearing loss and limited word discrimination retain substantial residual hearing in the low frequencies. In this case, the audiology report demonstrates that the patient has minor residual hearing in the low frequencies with steeply sloping to profound hearing loss in both ears. In addition, the AzBio test in the left ear with the hearing aid confirmed 74% correct responses for words alone, and 35% correct responses in sentences. Thus, the request for left ear cochlear device and implantation with or without mastoidectomy has not been established as 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT) and image guided radiation therapy (IGRT) for treatment of the enrollee who has been diagnosed with cutaneous basal cell carcinoma.  Findings:  Two physician reviewers found that there is a growing body of literature supporting the use of IMRT for extremity sarcoma.  The use of radiation treatment for resected, node positive skin cancer is a standard treatment. IMRT is a tool that clinicians can use when there is concern about sparing normal tissues from high dose exposure. For extremity soft tissue sarcomas, IMRT is used to spare bones, joints, lymphatic channels, nerves and critical organs.  IMRT is often better suited for extremity sarcomas than conventional radiation, because of the concave dose distribution, which is difficult to achieve with conventional radiation. IMRT is another effective means to deliver radiation.  In general, IMRT can be clinically meaningful in the reduction of normal tissue exposure and/or target coverage. From the provided records, and the description of where the target is located, IMRT is a more effective manner to treat the target and to spare the surrounding normal tissues than 3-dimensional (3D) conformal radiation. The use of IMRT is adequately justified in this case. With regards to IGRT, this procedure is generally done in conjunction with IMRT. Because IMRT is a conformal way to deliver radiation, IGRT is needed to verify set up on a daily basis. Therefore, IMRT and IGRT are likely be more beneficial for treatment of this patient than the standard 3D conformal radiation. 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: Reviewers 1, 2 and 3 are board certified in radiation oncology 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 reimbursement for residential treatment center (RTC) services provided Findings:  The physician reviewer found that the records indicate that this patient was not a danger to himself or others, he was not aggressive or violent, he was not self-harming, and he was not gravely disabled. He was medically and psychiatrically stable to the extent that he did not require treatment in a 24-hour facility. There were no emotional, behavioral, or cognitive to warrant the RTC level of care. There was no evidence of a high degree of impulsivity, psychosis, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He demonstrated ongoing depression and anxiety, but these conditions did not require residential treatment. He was accepting of the principles of treatment, was motivated, and involving himself in his recovery. No new problems had arisen. He was cooperative and participating in his treatment plan. He was medication compliant, and no medication changes had been made since admission. He had a stable home environment with supportive parents. He no longer met the medical necessity guidelines for RTC level of care and could have been successfully treated at an ambulatory level of care with concomitant sober living. Thus, the RTC services provided were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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.