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 custom shoe orthotics for treatment of the enrollees foot pain. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of custom shoe orthotics. A review of guidelines indicate orthopedic foot wear including shoes, inserts, or modifications to shoes for patients without diabetes are not considered medically necessary. Some bracing is considered medically necessary if a shoe is also an integral part of a leg brace. These criteria are not supported in the documentation provided. In addition, a review of the documentation provided does not indicate that the foot orthotic would alleviate the patients limb length discrepancy or foot pronation. There is a lack of support in the peer-reviewed literature demonstrating that orthotics are more effective than standard therapy for the treatment of the patients medical condition. As such, the request for custom shoe orthotics is not medically necessary for treatment of the patients medical condition. 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 podiatry 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 individual weekly psychotherapy for treatment of the enrollees depression and trauma. Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for patients afflicted with major depressive disorder. Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. Individual psychotherapy is a standard treatment intervention of major depressive disorder, and a brief course of individual psychotherapy is warranted in this patients case. Such treatment could help build a therapeutic rapport by capitalizing on the principles of patient centricity, prepare the patient for a transition to the group setting and/or community programming, and facilitate additional evaluation for consideration of other treatments, such as cognitive behavioral therapy for pain, trauma-focused therapy or dialectical behavioral therapy. The American Psychiatric Association (APA) suggests that time-limited brief psychotherapies may mobilize many depressed patients to more rapid improvement. In addition, the provider should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of provider and patient rated scales at regular intervals. If eight weeks of treatment does not yield at least moderate improvement with 20% or greater diminution in symptoms, the provider should thoroughly review and reappraise the treatment plan. As such, a course of eight individual therapy appointments delivered once a week over a span of eight weeks with systematic monitoring and re-assessment of the patients clinical needs upon conclusion of the treatment episode would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Accordingly, a portion of the requested services are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high dose radiation for treatment of the enrollees T1N0 estrogen receptor (ER) positive, progesterone receptor (PR) positive, infiltrating ductal carcinoma of the left breast. Findings:  The 3 physician reviewers found that accelerated partial breast irradiation (APBI) is a method for focused delivery of radiation therapy as opposed to the commonly applied whole breast irradiation approach. Whole breast irradiation is usually applicable to patients with invasive breast cancer who have undergone breast conservation surgery. APBI is applied as adjuvant therapy to prevent local recurrence of breast cancer. In 2010, a publication appeared showing that patients who were classified into the unsuitable category by the guidelines cited above had good outcomes with APBI. Colleagues published data showing that the categories established by the American Society of Radiation Oncology (ASTRO) guidelines did not show statistically significant differences in ipsilateral breast cancer recurrence. Finally, recent data colleagues evaluated 1,200 breast cancer patients after randomization into APBI versus whole breast radiation. Outcomes for breast cancer recurrence were not statistically different between the two cohorts with reduced skin toxicity in the cohort receiving APBI. Based on these compelling data and new rigorous medical evidence, APBI is an acceptable technique for use in this clinical setting. Thus, the high dose radiation provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the services at issue were 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 Vemlidy 25 mg for treatment of the enrollees chronic hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg is supported as medically necessary for the treatment of this patients chronic hepatitis B. 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 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 authorization and coverage for acupuncture for treatment of the enrollees neck pain and back pain. Findings:  The physician reviewer found that the records indicate that this patient has had extensive acupuncture treatment for over three years and 51 treatments with no documented improvement. The patient has been recommended for surgery but has declined. In this clinical setting, acupuncture is not indicated as more effective than standard medical treatment for chronic pain. Given the lack of improvement in the acupuncture records provided for review, further treatment is unlikely to produce improvements not already realized. Thus, the requested acupuncture is not supported as medically necessary for treatment of this 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 acupuncture 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 Cosentyx for treatment of the enrollees plaque psoriasis and psoriatic arthritis. Findings:  The physician reviewer found that the patient presents with a history of plaque psoriasis and psoriatic arthritis. However, there is no documentation that the patient cannot tolerate treatment with the preferred formulary agents adalimumab (Humira) or ustekinumab (Stelara). Colleagues noted that analysis showed adalimumab, secukinumab, and ustekinumab were comparable in terms of high efficacy and tolerability. As the patient has not failed therapy and has no reported contraindication to either Humira or Stelara, the requested treatment with Cosentyx is not supported as medically necessary for treatment of the patients plaque psoriasis and psoriatic arthritis. 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 authorization and coverage for Genotropin for treatment of the enrollee, who has a reported diagnosis of pediatric growth hormone deficiency. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not more than two standard deviations below the mean for age and gender, growth velocity is normal, bone age is not delayed, and growth factors are normal. Provocative growth hormone testing has poor sensitivity and specificity for a diagnosis of growth hormone deficiency in the absence of auxological criteria consistent with the diagnosis. Thus, the fact that the patient had a suboptimal growth hormone response to testing does not indicate that he is growth hormone deficient. All told, Genotropin is 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 pediatrics with sub-specialty certification in pediatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for an additional five (5) hours per week (260 units) of direct applied behavioral analysis (ABA) therapy (Code 0365T) for treatment of the enrollees autism.Findings:  The physician reviewer found that in this case, the patient demonstrates significant delays in social skills and adaptive skillsets along with significant outbursts of self-injury and aggression. The patient continues to require a high level of behavioral support as evidenced by the treatment goals set forth by the treating provider. Failure to demonstrate progress in these areas puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 FoundationOne test for evaluation of the enrollees left hilar mass. Findings:  2/3 of the physician reviewers found that Foundation One is a molecular assay that explores the mutations of an individual patients cancer cells. The goal of the assay is to identify a specific mutation or target which could guide the provider as to which chemotherapeutic agent would be useful. However, there is a paucity of evidence that the Foundation One assay adds to decision making ability, or yields a result that is reliably clinically beneficial. There are non-randomized studies exploring the value of molecular profiling, but the results have not been convincing as to the efficacy of such an approach to treatment. A randomized trial did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Currently, the data suggests that finding a mutation does not support treatment directed at that target to produce a clinically meaningful response. All told, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for right sacroiliac (SI) joint fusion using the IFuse Implant system for treatment of the enrollees SI joint pain. Findings:  2/3 of the physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Colleagues compared SI joint fusion using triangular titanium implants to nonsurgical management. The conclusions were that at six-month follow-up the minimally invasive SI joint fusion using triangular titanium implants was more effective than nonsurgical management in relieving pain, improving function, and improving quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruptions. Based upon a review of the peer-reviewed literature, the request for minimally invasive right SI joint fusion is clinically indicated for this patient. Furthermore, the proposed IFuse Implant system is proven to be safe and effective in multiple documented studies. Therefore, the requested right SI joint fusion using the IFuse Implant system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: 2/3 of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 authorization and coverage for bilateral cochlear implants for treatment of her bilateral profound sensorineural hearing loss post bilateral cochlear implants.Findings: The physician reviewer found that The records indicate the provider recommended replacement of this patients bilateral cochlear implants because the current sound processor is of an older generation and a new processor is available that has added features. This patient does have adequate cochlear implant on the contralateral side with the sound processor which appears to be functioning. Although the patients current sound processor is of an older generation, it remains partially functional and the cochlear implant on the contralateral side is indicated to be functioning. Thus, the request for replacement of the patients bilateral cochlear implants is not medically necessary for treatment of this patients sensorineural hearing loss.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 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.