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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested physical therapy for treatment of her cervical radiculopathy.   The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity of physical therapy has not been established. The study by Fritz and colleagues found that the addition of traction to exercise therapy improves clinical outcomes. In this study the subjects had four weeks of treatment and showed continued benefit a year later. Thoomes and colleagues conducted a systematic review of conservative care for cervical radiculopathy, concluding that On the basis of low-level to very low-level evidence, no 1 intervention seems to be superior or consistently more effective than other interventions. Regardless of the intervention assignment, patients seem to improve over time, indicating a favorable natural course. In this case, the patient has had extensive physical therapy with recurrent weakness and pain. She complains of symptoms such as returning/worsening pain when she is not in physical therapy. Based on the patients initial onset of symptom and recurrence of symptoms, additional physical therapy as a form of conservative care is not supported as medically necessary.  Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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:   The parent of an enrollee has requested sensory processing integration therapy for treatment of the enrollees autism and sensory processing disorder. Two physician reviewers found that the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Sensory processing disorder is described as an overload of receiving sensory perceptions which in-turn leads to an over-response of behaviors.  The present concept is that an autistic patients abnormal behaviors stem from an over-response to environmental stimuli and treatment of his sensory processing disorder can only be treated by highly qualified and a specifically trained occupational therapist. Sensory integration therapy has a robust medical literature as to its long-term value. Miller and colleagues report significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. In this case, the patient was specifically tested for sensory processing dysfunction and multiple sensory processing deficiencies were documented.  Given the support in the medical literature, sensory processing integration therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested therapy 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 pediatrics and neurology with sub-specialty certification in neurodevelopmental disabilities and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cervical total disc arthroplasty for treatment of his medical condition.  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  There are general concerns regarding cervical artificial disc replacement.  Studies of longer duration are needed to assess the longer term potential complications of a methyl methacrylate arthroplasty within the cervical spine.  It is known that the metal to methyl methacrylate bearing surface will be exposed to the wear mechanisms of abrasion, adhesion, fatigue and third body wear.  A continuing particulate load of these particles will occur.  The patients specific response will be influenced by the response of the immune system, but it is known that there is a universal giant cell reaction and chronic inflammation in response to wear debris.  Additionally, it remains controversial whether motion at the replaced intervertebral disc will be maintained over time.  The question of whether total disc arthroplasty as compared to arthrodesis will be beneficial in terms of adjacent segment degeneration remains controversial both by reason of gradual loss of motion at the arthroplasty index site and by the possibility that adjacent segment degeneration is an expression of a progressive disease process rather than a complication of arthrodesis itself.  All told, the requested cervical total disc arthroplasty is not likely to be of greater benefit than other treatment options.   Final Result: Two 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment for treatment of his behavioral health conditions. The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Per the medical records, the patients opiate use dominated his daily routine and generated distress.  He had strained relations with his family, and he did not have an established sober peer group.  He had failed outpatient treatment.  Despite starting escitalopram for mood and anxiety, the record indicates that the patient was anxious and dysthymic.  When considering the illness presentation in context of the history and psychosocial factors, the patient had not consolidated the treatment gains needed to facilitate a successful discharge.  The residential setting was reasonably expected to improve his condition and prevent a more serious episode of illness.  The duration of treatment was consistent with community standards.  All told, residential treatment was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intraoperative radiation therapy (IORT) with external beam for treatment of her breast cancer.  Three physician reviewers found that there are various methods to deliver partial breast radiation including LINAC based, interstitial brachytherapy catheters, Mammosite balloon, IORT with a portable LINAC, and electronic brachytherapy. At least one study has shown that electronic brachytherapy has less dose deposition outside of the target volume. Electronic brachytherapy as a sole modality was investigated in the TARGIT A study, which involved multiple institutions and randomized 3,451 women to partial breast radiation alone delivered via electronic brachytherapy versus whole breast radiation. The authors concluded that, TARGIT concurrent with lumpectomy within a risk-adapted approach should be considered as an option for eligible patients with breast cancer carefully selected as per the TARGIT A trial protocol. Currently, IORT with electrons and electronic brachytherapy are emerging technologies, without long-term outcome data for breast cancer. IORT is a means to deliver radiation, but has not been accepted as standard therapy for breast cancer. Overall, there is a paucity of data to suggest that the IORT with external beam was likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 radiation 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 spinal stenosis surgery for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical literature recommended surgery for spinal stenosis for patients who do not improve with conservative treatment.  The current peer-reviewed literature supports spinal stenosis surgery in this clinical setting.  This patient presents with evidence of severe stenosis and radiculopathy.  Detailed evidence of a recent, comprehensive non-operative treatment protocol trial and failure has been submitted.  All told, spinal stenosis surgery is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for 24 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1b. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), this patient should be considered high priority for therapy due to cirrhosis. However, the only recommended therapy for patients with cirrhosis who have failed a regimen of Sovaldi and ribavirin is Harvoni and ribavirin for 24 weeks. This recommendation is based on studies showing high cure rates approaching 100% after failure of Sovaldi and ribavirin for 24 weeks, even in patients with cirrhosis. There is a lack of current peer-reviewed published evidence to support the use of Viekira Pak in a patient who has failed therapy with Sovaldi and ribavirin. Based on these guidelines, the requested Viekira Pak for 24 weeks is not medically necessary for treatment of this patients chronic hepatitis C virus infection. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested therapy. ABA therapy is the standard of care in the therapeutic intervention of autistic children and the documentation submitted for review has confirmed a diagnosis of autism. According to the physicians Children who receive early intensive behavioral treatment have been shown to make substantial, sustained gains in IQ, language, academic performance, and adaptive behavior as well as some measures of social behavior, and their outcomes have been significantly better than those of children in control groups. Therefore, ABA therapy is medically necessary and should be provided for this patient.Final Result: Two reviewers determined that the requested therapy is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing.  One reviewer is board certified in neurology with special competence in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of her medical condition.   The physician reviewer found that there is sufficient support for the requested medication in this patients case.  The records indicate that the patient has stiff person syndrome, a rare autoimmune disorder, with anti-glutamate decarboxylase antibodies.  She has been treated with diazepam and monthly intravenous immunoglobulin without adequate response.  Due to the rarity of this disorder, there is a lack of adequately powered, placebo-controlled, double-blind randomized trials.  The literature indicates that benzodiazepines are considered first-line therapy to reduce stiffness.  It is medically reasonable to offer a trial of Rituxan in this case, given the failure of intravenous immunoglobulin and diazepam.  Plasmapheresis and mycophenolate mofetil are also noted to be potentially beneficial, but there is no proven stepwise strategy available in the management of this disorder.  All told, Rituxan 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 24 week course of Sovaldi and ribavirin for treatment of his chronic hepatitis C virus genotype 3a. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines recommend treatment with daily Sovaldi and weight-based ribavirin for 24 weeks for treatment of genotype 3 hepatitis C in interferon-ineligible patients. This is based on the U.S. Food and Drug Administration (FDA) approval which recommends 24 weeks of therapy and on the VALENCE trial. The trial found a higher rate of sustained virologic response in patients who had 24 weeks of therapy than patients who had shorter therapy in the FISSION and FUSION trials. Consistent with these findings, the requested 24 week course of Sovaldi and ribavirin is supported as medically necessary for treatment of this patients hepatitis C virus infection genotype 3a. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Namenda for treatment of his multiple sclerosis with cognitive deficits. Findings:  The physician reviewer found that there is a lack of support in the medical literature demonstrating that memantine has a therapeutic effect in the treatment of MS related cognitive disorder. He and colleagues performed randomized controlled trials (RCTs) involving 625 patients with relapsing-remitting, secondary-progressive and primary-progressive MS, evaluating the absolute efficacy of donepezil, ginkgo biloba, memantine and rivastigmine versus placebo in improving memory performance with diverse assessment scales. The authors concluded that We found no convincing evidence to support the efficacy of pharmacological symptomatic treatment for MS-associated memory disorder because most of available RCTs had a limited quality. Whether pharmacological treatment is effective for memory disorder in patients with MS remains inconclusive. Given the lack of support in the medical literature, the requested medication is not medically necessary for treatment of the patients medical condition.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 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 brachytherapy with catheter placement for treatment of her ductal carcinoma in situ. Findings:  Two physician reviewers found that brachytherapy is a form of radiation therapy that involves the implantation of radioactive seeds or sources in or near an existing tumor to maximize delivery of radiation to cancerous cells while minimizing exposure and potential damage to adjacent normal structures.  High dose rate brachytherapy consists of the placement of thin catheters into the tumor.  There has been recent interest regarding the use of brachytherapy for the treatment of breast cancer.  There are a few published trials in the medical literature suggesting safety and efficacy of brachytherapy.  However, there is a lack of randomized or long-term cohort trials for long-term clinical outcome compared to external beam radiation therapy.  Additionally, National Comprehensive Cancer Network guidelines do not recommend this treatment for patients younger than 60 years of age.  Thus, the current medical evidence has not established the superior efficacy of the requested brachytherapy with catheter placement in this patients case.  Final Result: Two 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 radiation 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: The parent of an enrollee has requested partial hospitalization program (PHP) for eating disorders treatment for treatment of the enrollees anorexia nervosa.  Findings:  The physician reviewer found that according to the American Psychiatric Association (APA) criteria, this patient is medically stable. Her weight is generally above 80% of her ideal body weight. She seems to have fair motivation and is generally cooperative, although still needs to have reinforcement at times to continue her treatment. She still needs some structure to continue her program, but is eating her meals. Although she requires some additional structure beyond self-control to prevent her from compulsive exercising, she does not require the intensity of PHP services. She does not purge and does have a supportive environment. According to the APA guidelines, she most closely meets criteria for treatment at the intensive outpatient program (IOP) level of care. All told, the PHP for eating disorders treatment services provided were not and are not medically necessary for treatment of this 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 with sub-specialty certification in child and adolescent 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.