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 of MRI of the lumbar region. The American College of Radiology (ACR) appropriateness criteria for the evaluation of low back pain notes that most patients presenting with uncomplicated acute low back pain or radiculopathy do not require imaging. However, the ACR recommends that if symptoms persist following four to six weeks of conservative management, if there is suspicion for serious underlying conditions, or if the patient is a surgical or intervention candidate, then MRI of the lumbar spine may be appropriate. In this case, the patient is status post surgery with acute recent onset of low back pain, and has tried and failed anti-inflammatory drugs and physical therapy. An MRI may evaluate postoperative complications, such as a postoperative seroma compressing the nerve roots, a bone fragment, or residual disc herniation. Given that this patient has worsening symptoms following surgery and has exhausted  conservative therapy, the requested MRI is medically indicated. Therefore, MRI of the lumbar region is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for  proton beam therapy (CPT 77520, 77522, 77523, and 77525). This patient presents with a history of prostate cancer with recent recurrence. A prostate biopsy on 3/15/20 showed involvement of the prostate gland bilaterally by a combination of a Gleason 3+3 and 3+4 adenocarcinoma. The patients provider has recommended proton beam therapy in lieu of standard IMRT and other standard treatment modalities. Proton beam radiation therapy for prostate cancer in a patient previously treated with radiotherapy to the pelvis has not been demonstrated to be superior to prostatectomy or IMRT. Per the American Society for Radiation Oncology (ASTRO), 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. A systematic review by Verma and colleagues evaluated available evidence regarding proton beam therapy re-irradiation. The authors investigated patients with central nervous system, head/neck, lung and gastrointestinal malignancies. The authors noted, Based on the limited existing data, proton beam therapy is a notably safe re-irradiation modality for effective salvage of recurrent disease. It is important to note that this systematic review did not evaluate re-irradiation in the setting of prostate cancer. At this time, there is a lack of evidence supporting re-irradiation with proton beam therapy for this patient with prostate cancer. Thus, the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested proton beam therapy (CPT 77520, 77522, 77523, and 77525) 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 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 authorization and coverage for a colonoscopy. Findings:  The physician reviewer found that United States Preventive Services Task Force (USPSTF) recommendation for colorectal cancer screening states, The USPSTF did not specifically review the evidence on screening in populations at increased risk; however, other professional organizations recommend that patients with a family history of colorectal cancer (a first-degree relative with early-onset colorectal cancer or multiple first-degree relatives with the disease) be screened more frequently starting at a younger age, and with colonoscopy. The American Cancer Society (ACS) noted that people at increased or high risk of colorectal cancer might need to start screenings before age 45, or be screened more often, but stated that the ACS does not have screening guidelines specifically for people at increased or high risk of colorectal cancer. Wilkins and colleagues advise individuals who have a first-degree relative with colorectal cancer diagnosed before age 60 to start screening colonoscopies at 40 years of age or 10 years younger than the earliest diagnosis in their family, whichever comes first. In this case, the patient has a family history of colorectal cancer, with a first-degree relative diagnosed at age 38. Under current guidelines, a screening colonoscopy based on the patients family history of colon cancer is not medically indicated. There is no documentation of symptoms which would warrant a colonoscopy, such as bleeding, unintentional weight loss, or anemia. Therefore, a colonoscopy is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested service 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 patient has requested authorization and coverage for Harvoni tablets for eight weeks. Findings: Guideline recommendations for the treatment of hepatitis C state, From a medical standpoint, data continue to accumulate that demonstrate the many benefits, both intrahepatic and extrahepatic, that accompany hepatitis C virus (HCV) eradication. Therefore, the panel continues to recommend treatment for all patients with chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV treatment, liver transplantation, or another directed therapy.` Given that it is standard accepted therapy for the treatment of hepatitis C, the requested medication is medically indicated. Therefore, Harvoni tablets for eight weeks are medically necessary 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 internal medicine with sub-specialty certification in infectious disease 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 bilateral knee replacement surgery. Current medical literature supports total knee arthroplasty for well-selected patients with arthritis who have not improved despite adequate conservative treatment. Accepted indications include pain that interferes with activities of daily living and sleep, physical findings of advanced osteoarthritis, imaging evidence of advanced osteoarthritis, failed non-operative treatment, and absence of relative contraindications. In this case, there is evidence of severe pain rated 8/10, a history of frequent locking, and imaging studies demonstrating advanced osteoarthritis in both knees with associated deformity. In addition, the patient has exhausted conservative treatment modalities and there are no reported major contraindications to surgery. Given these findings, the requested bilateral knee replacement surgery 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 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 patients parent has requested authorization and coverage for foot orthotics/shoe inserts. Medical literature note that most disease conditions that affect the hallux are amenable to conservative treatment prior to focusing on surgical management. In this case, the patient is a cross-country track runner who reports pain in the ball of the right foot for the past three months, aggravated when running. The patients diagnoses include pain in the right foot and sesamoiditis. The provider recommends that the patient be casted for functional orthotics in order to decrease pronation, decrease stretch of the plantar fascia, delay the formation of bunions, delay the formation of hammertoes, increase shock absorption, and prevent surgery. In this clinical setting, the requested equipment is medically indicated. Therefore, foot orthotics/shoe inserts are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 podiatrist 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 proton beam radiation therapy services. Per the medical literature, there is a lack of clinical data suggesting that treatment with palliative proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for treatment to the craniospinal axis. In the majority of cases, the standard approach to treat this malignancy is with standard photon techniques using intensity modulated radiation therapy (IMRT). In this case, the comparative plan demonstrated that standard treatment methods were sufficient to treat this patient. The proton therapy plan did not result in a meaningful clinical difference, despite having lower dose to the organs. Consensus group guidelines do not support the use of proton therapy in this setting. There is a lack of level I evidence to support the use of proton beam therapy during palliative radiotherapy. Therefore, proton beam radiation therapy services were not medically necessary for the 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 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: The patients parent has requested authorization and coverage for continued speech therapy. The records provided for review demonstrate that this patient has made gradual progress with speech therapy as noted during his evaluation. The American Speech-Language-Hearing Association (ASLHA) reports that, Childhood apraxia of speech (CAS) is a neurological childhood (pediatric) speech sound disorder in which the precision and consistency of movements underlying speech are impaired in the absence of neuromuscular deficits. With regard to treatment, researchers described that young patients with CAS may also have impairments in one or more of the following areas: non-speech oral motor function, dysarthria, language, phonological production impairment, phonemic awareness or metalinguistic skills and literacy, or combinations of these. This patients provider reports slow progress but noted that the patient continues to exhibit severe impairments across receptive, expressive and speech production skills. Consistent with the current medical literature and ASHA guidelines, continued speech therapy is appropriate as recommended by the patients provider. All told, the requested continued speech therapy 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for RTC services. The Child and Adolescent Level of Care Utilization System (CALOCUS) provides a framework for determining the clinically appropriate level of care for a child or adolescent in mental health treatment. With regard to risk of harm, the records support a score of 3. The patient was at risk due to a history of suicidal ideation in the last year, familial dynamic issues and conflicts, and substance abuse. In terms of functional status, the records support a score of 4. The documentation noted serious functional impairment due to serious deterioration of interpersonal interactions with consistent conflict with his mother and physical aggression. With regard to comorbidity, the records support a score of 4. The patient had significant comorbidity, due to the presence of parent-child conflict, substance abuse, depression, oppositional defiant  disorder, and PTSD.In terms of level of stress of the recovery environment, the records support a score of 4. The patient had a stressful environment due to struggles with family dynamics.With regard to level of support of the recovery environment, the records support a score of 3 due limited support and a good relationship with his father, and a challenging relationship with his mother. In terms of resiliency and treatment history, the records support a score of 4. The patient had poor resiliency and/or response to treatment, as evidenced by his relapse on substances between discharge and readmission. With regard to treatment acceptance and engagement, the records support a score of 2. The patient has participated in treatment, with ongoing challenges in insight and judgement. Thus, the patient has a total score of 24. In this case, the recommended level of care is medically monitored residential level of care. This is consistent with the level of care that the patient received at the RTC. Additionally, the patients functional status score of 4 supports residential level of care. Therefore, RTC services were medically necessary for the treatment of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for lumbar fusion surgery services. Researchers found that in patients with degenerative grade 1 spondylolisthesis, fusion significantly improves quality of life versus simple decompression alone. The records provided for review document a longstanding history of chronic back pain that has persisted despite at least six months of conservative care. Treatment modalities have included physical and aquatic therapies, medications, yoga, and chiropractic care. The patient has been treated by pain management for over two years. Steroid injections were initially beneficial but were less effective just prior to surgery. In addition, there is report of imaging studies demonstrating a structural and progressive source for the patients symptoms. There are magnetic resonance imaging (MRI) studies and x-rays that show evidence of a progressive isthmic spondylolisthesis with severe left-sided foraminal stenosis at L4-5 or L5-6, and meaningful and substantial instability. The flexion and extension films demonstrated 5 mm or greater of moving listhesis at the affected level, which supports instability. Moreover, there is greater listhesis on upright x-rays versus his MRI scan. Finally, the process has been rapidly progressive, with his first provided MRI documentation reporting a mild anterolisthesis in 2018, to standing films that note a grade 2 spondylolisthesis just prior to surgical intervention in 2020. A recent review of guidelines also supports the use of fusion procedures in appropriately selected patients who have failed conservative therapies. In this case, the current patients condition included a higher grade isthmic spondylolisthesis that was unstable. Spinal fusion, in conjunction with decompression was the treatment of choice for the management of this patients higher grade isthmic unstable spondylolistheses. For these reasons, the lumbar fusion surgery services were medically necessary for treatment of this patient. 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 neurological 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

Xyosted (testosterone enanthate) is an FDA-approved medication for treatment of male hypogonadism. A clinical trial was done to evaluate the efficacy and safety of a subcutaneous testosterone enanthate auto-injector administered weekly to men with hypogonadism. The conclusion of the trial noted the dose adjusted subcutaneous testosterone enanthate auto-injector demonstrated a steady serum total testosterone pharmacokinetic profile with small peak and trough fluctuations. The clinical trial  found that the device was safe, well tolerated and virtually painless, indicating that subcutaneous testosterone enanthate auto-injection offers a testosterone delivery system that is a convenient weekly option to treat testosterone deficiency. Another clinical trial was done of patients with symptomatic testosterone deficiency and concluded that the subcutaneous testosterone enanthate auto-injector has a favorable safety profile and is well-tolerated, with a stable pharmacokinetic profile. Studies have also shown that it is less painful than intramuscular injection. Xyosted is therefore a good option for men who are unable to continue intramuscular injection therapy. In this case, the patient has symptomatic hypogonadism that responded to testosterone replacement therapy with intramuscular injection of testosterone cypionate. The patient is unable to tolerate this treatment, however, due to pain at the injection site.The patient also has concerns about topical therapy with the risk of exposure to his family. The patient was placed on Xyosted subcutaneous injections, and he tolerated subcutaneous injection well and noted improvement in his symptoms and testosterone levels. Under these circumstances, the requested medication Xyosted is medically necessary to treat the patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary to treat the patient's 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.