Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Based on the records provided, this patient presented to his provider with some cardiovascular risk given his history of hypertension. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology Foundation (ACCF) and American Heart Association (AHA) do not support routine advanced lipoprotein testing (Greenland, et al.; Stone, et al.). These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein (a), Apo A-1, and homocysteine. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Therefore, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the advanced lipoprotein 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 reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease 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 Mono HDR Brachytherapy.The medical literature supports that the requested Mono HDR Brachytherapy is medically necessary. Current guidelines state that brachytherapy can be used as a standard treatment option in patients. Long term data on patients treated with brachytherapy alone show that they have equivalent outcomes to conventional external beam radiation therapy.  Brachytherapy is considered a standard treatment option for patients with intermediate prostate cancer and has been endorsed by guidelines for over 20 years.In this case, the patient has favorable intermediate risk prostate cancer. The medical literature supports that Brachytherapy is a standard treatment option for patients with intermediate prostate cancer. Under these circumstances, the requested Mono HDR Brachytherapy is medically necessary to treat 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 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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for proton beam radiation therapy.  The position statement from the American Society for Radiation Oncology (ASTRO) states that, 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 (NCCN) guidelines endorse the position statement by ASTRO. The NCCN noted that photons with IMRT is considered the standard of care in this clinical setting. Researchers compared IMRT and proton therapy for localized prostate cancer. The authors found that patients treated with IMRT reported a lower rate of gastrointestinal morbidity than patients treated with proton beam radiation therapy. Researchers found no difference in toxicity between PBRT and IMRT in a cohort of patients with prostate cancer at 12 months post-treatment. This patient has prostate cancer without evidence of metastasis. Therefore, proton beam radiation therapy was not and is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Axumin positron emission tomography (PET) scan. The current medical evidence supports the requested services in this clinical setting. This patient has a history of prostate cancer, and the records noted increasing PSA levels. Axumin PET scanning is utilized to localize recurrent disease in patients with a history of prostate cancer with increased PSA. The sensitivity of Axumin PET scans increases with increasing PSA values. In this case, there is significant clinical suspicion for disease recurrence due to increasing PSA values as well as MRI findings. The Axumin PET scan is a sensitive examination to detect the site of suspected recurrence. Therefore, Axumin PET scan is medically necessary for the evaluation of this patient. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for increased dosage of Stelara from every eight weeks to every four weeks. Current medical literature supports dose escalation of Stelara in this case. The patient has active disease symptoms. One large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). The mechanism of Stelara is different than that of anti-TNF medications, which this patient has failed (Tuskey and Behm). In an effort to address inadequate disease control, one study showed that a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks (Kopylov, et al.). Multiple studies have shown that a majority of patients in whom Stelara dosing every eight weeks failed to control symptoms responded to dosing every four weeks (Wils, et al.; Battat, et al.; Khorrami, et al.). This patient has a severe disease that has required surgical intervention. Continuation of the current dose may result in further complications. For these reasons, an increased dosage of Stelara from every eight weeks to every four weeks is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found an increased dosage of Stelara from every eight weeks to every four weeks 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 increased medication dosage 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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

The enrollee is requesting authorization and coverage for the medication VersaBase. The enrollee is a post-menopausal female on hormone replacement therapy (HRT). During an office visit with her obstetrician-gynecologist, she stated she wanted to continue compounded therapy because she tolerated it well. She considered switching to an FDA-regulated bioidentical HRT, but when she tried patches, Estradiol and Premarin, she experienced cramping, nausea and diarrhea. She has been taking VersaBase for over five years for hormone dysfunction. All other medications available for this condition failed due to allergic reactions and gastrointestinal problems. After a through examination and detailed history, her physician determined she should stay on the same medication as it has worked well for her.The physician reviewer found the use of compounded preparations of hormones, known as bioidentical hormones, for the treatment of menopausal symptoms can be an attractive alternative for those suffering from unrelieved menopausal symptoms. These compounds should be approached with caution. Professional societies warn the ability to accurately assess and measure potency, efficacy, and quality of the preparations is lacking. Furthermore, these compounds are not FDA-approved.Additional concerns surfaced regarding the nature of these compounds and their impacts on overall health and well-being when a correlation was discovered by Australian researchers between endometrial cancer and the use of these unregulated compounds. A professional societys position statement has remained unchanged on this issue since 2006; the compounds are not recommended. Further, these compounds have not been studied comprehensively, and there is no definitive evidence regarding the safety of these compounds. Claims to the contrary have no scientific foundation for their validity.The physician reviewer found that determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in obstetrics and gynecology and 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. The American Psychiatric Association (APA) treatment guidelines state that RTC or similar care higher than outpatient be recommended for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use...lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. Per the American Society of Addiction Medicine (ASAM) guidelines, this patient meets ASAM criteria for clinically managed high-intensity residential services such as RTC level of care. For dimension 1, intoxication/withdrawal potential, the patient has demonstrated withdrawal symptoms of palpitations, elevated blood pressure, and body aches. The records also note tremors, sweating, fatigue, and agitation. For dimension 2, biomedical issues, the patient has shown weakness, coordination problems, and poor sleep. For dimension 3, emotional, behavioral and cognitive issues, the patient has bipolar disorder and PTSD. For dimension 4, readiness to change, the patient has been pre-contemplative regarding steroid use and remains ambivalent about sobriety. For dimension 5, relapse/continued use problem potential, the patient minimizes the seriousness of his condition and remains unaware of his triggers. For dimension 6, recovery environment, the patient has strained relationships. Given the severity of the patients illness, the RTC services provided were and are medically necessary for treatment of this patient.  Final Result: The reviewer determined that the services at issue were and 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 psychiatry with expertise in addiction 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: The patient has requested authorization and coverage for Toremifene Citrate. Toremifene is U.S. Food and Drug Administration (FDA) approved for the treatment of metastatic breast cancer. However, Toremifene does not have an approved role for adjuvant treatment of breast cancer. The current medical literature and National Comprehensive Cancer Network (NCCN) have specific recommendations for medications in this clinical setting including tamoxifen, or other aromatase inhibitors such as Letrozole or exemestane. Therefore, Toremifene Citrate 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 internal medicine with subspecialty certifications in medical oncology and hematology 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 a power wheelchair. The documentation reveals that this patients mobility deficit may be safely and adequately resolved with the use of an appropriately fitted walker as per the DME evaluation. The providers assessment was that a power mobility device is premature and the patient could benefit from a four-wheeled walker with a seat. Further, the patient has significant in-home support with instrumental activities of daily living (ADLs). Overall, the records indicate that the patient should be able to participate in one or more ADLs within the home with use of an appropriately fitted walker. Therefore, the requested power wheelchair is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 subspecialty 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a nerve block epidural.The submitted documentation supports that the requested nerve block epidural is medically necessary. Current evidence suggests that lumbosacral transforaminal epidural steroid injection (TFESI) is an effective treatment for lumbosacral radicular pain. In this case, the patient has low back and right sided radicular pain. She benefitted from a prior epidural steroid injection, and underwent a microdiscectomy at L4-5 with 50% relief for 6 months. Her provider has documented recurrent low back and radicular pain, and has administered epidural steroid injections at two levels with 40% relief. The provider has requested a third epidural steroid injection at L2-3 based upon the dermatomal distribution of pain. Under these circumstances, the requested nerve block epidural is supported by medical literature and appropriate to treat the patients low back and radicular pain. Therefore, the requested nerve block epidural is medically necessary to treat the patients medical condition.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for dual diagnosis residential treatment center services.The submitted documentation supports that dual diagnosis residential treatment center services were, and are, medically necessary. Applying the American Society of Addiction Medicine (ASAM) dimension analysis for placement with substance use disorders, the patient has met Level 3.5 criteria for Clinically Managed High-Intensity Residential Services. For dimension 1, intoxication/withdrawal potential, the patient displayed post withdrawal symptoms of aches, tingling, yawning, fatigue, appetite changes, and irritability that could be safely managed in a Level 3.5 setting. For dimension 2, biomedical conditions and complications, the patients medications include naltrexone, Wellbutrin, Prozac, and Topamax, and the patient needs monitoring for medication compliance, effect and side effects, and for his suicidal/homicidal ideation. For dimension 3, emotional, behavioral, or cognitive conditions and complications, the patient demonstrated dysfunctional thinking, ambivalence about change, high risk behavior, irrational fears, anxiety, and he expresses bleak hopelessness about life with a history of suicide attempts. The patient also minimizes the risks of his use. For dimension 4, readiness to change, the patient is in the contemplation stage and is not committed to planning yet. For dimension 5, relapse, continued use, or continued problem potential, the patient is not honest with his parents and avoids responsibility for his health and recovery. For dimension 6, recovery environment, the patients social network is characterized by significant social isolation or withdrawal, as his network involves few persons outside of his parents, due to his behavior of pushing others away. As noted in this ASAM analysis, the patient has multidimensional needs and requires a safe and stable living environments in order to develop his recovery skills. This qualifies the patient for Level 3.5 treatment, which would correspond with the dual diagnosis residential treatment center services that have been provided to the patient. Accordingly, the dual diagnosis residential treatment center services provided to the patient were, and are, medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the services in issue and requested services were, and 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 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.