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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nerlynx. Nerlynx is an anti-HER2 drug that has been approved in breast cancer, but only for extended adjuvant therapy. Current studies are ongoing to assess the value of Nerlynx in the treatment of other cancers, with an attempt being made to correlate efficacy with certain HER2 mutations within a tumor cell. A study concluded that their series shows the chemosensitivity of HER2-driven NSCLC, and the potential interest of HER2-targeted agents. The authors noted that their results should help define the best therapeutic strategy for these patients and to orient future clinical trials. Overall, there is a paucity of clinical data demonstrating the safety and effectiveness of Nerlynx in NSCLC. For these reasons, the requested Nerlynx is not supported as medically necessary for treatment of this patients NSCLC. 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin infusion. There is sufficient support for the requested services in this clinical setting. The National Comprehensive Cancer Network guidelines indicate that prostate radiation is necessary for patients with metastatic prostate cancer. Researchers performed a recent meta-analysis and concluded that radiation therapy should be considered for men with metastatic hormone-sensitive prostate cancer with a low metastatic burden. This patient has local symptoms due to his prostate cancer and would derive a palliative benefit from prostate radiation. Intensity modulated radiation therapy techniques are necessary to reduce the radiation to the surrounding organs, including the bladder and rectum. Therefore, intensity modulated radiation therapy is medically necessary 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 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 Zembrace SymTouch pen injector. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Subcutaneous sumatriptan is highly effective for the acute treatment of migraine and has been approved by the U.S. Food and Drug Administration for this indication. The use of sumatriptan is medically necessary for the acute treatment of migraine when there are no medical contraindications. Zembrace has an easy-to-use self-injection system. Zembrace has been effective in this patients case. Therefore, Zembrace SymTouch pen injector services 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 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: Upheld Decision of Health Plan

The recent Federation of State Medical Boards guidelines for the Chronic Use of Opioid Analgesics state that continuation, modification or termination of opioid therapy for pain is contingent on the clinicians evaluation of (1) evidence of the patients progress toward treatment objectives and (2) the absence of substantial risks or adverse events, such as signs of substance use disorder and/or diversion. In addition, the guidelines state that providers should not continue opioid treatment unless the patient has received a benefit, including demonstrated functional improvement. Further, the American Pain Society guidelines regarding opioid therapy for non-cancer patients state that patients who are repeatedly non adherentmay requirediscontinuation of chronic opioid therapy. In this case, the records do not document the patients level of function has been improved with use of Percocet. Moreover, the records note lost medication, request for early refills, and other behaviors that are inconsistent with long-term opiate usage guidelines from the American Pain Society. All told, the requested Percocet is not supported as medically necessary for treatment of this patients chronic pain.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with subspecialty certification in pain management 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 and prospective authorization and coverage for Optune durable medical equipment device.Findings:  Three physician reviewers found Central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics. Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. Chemotherapy prolongs survival, but the gains are modest. The standard of care is to resect the tumors maximally, followed by treatment with temozolomide. This patient has exhausted these options. The device at issue has been approved by the U.S. Food and Drug Administration for the treatment of recurrent glioblastoma multiforme. There is sufficient medical evidence supporting the safety of the device at issue in this clinical setting. Thus, Optune durable medical equipment was and is likely to be of greater benefit than other treatment options.Final Result: The reviewers determined that the device at issue was and 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 sub-specialty certification in medical 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bronchial thermoplasty. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this patients case. Bronchial thermoplasty has been approved by the U.S. Food and Drug Administration. There have been multiple studies citing the benefit of the requested services in this clinical setting. Bronchial thermoplasty may improve asthma control and quality of life. This is a safe treatment for refractory asthma. In sum, the requested bronchial thermoplasty. Final Result: Two of the three physician reviewers found that he 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 reviewers 1, 2 and 3 are board certified in physical medicine and rehabilitation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A patient has requested authorization and coverage for Bacillus Calmette-Guerin (BCG) plus interferon (IFN) combination therapy. Based on a recent literature review from colleagues, there is a paucity of evidence demonstrating improved patient health outcomes with BCG plus interferon (IFN) compared with BCG treatment alone in patients with non-muscle invasive bladder cancer. Additionally, a recent review of the role of IFN-alpha in non-muscle invasive bladder cancer continues to describe that the use of IFN-alpha combination to be without clear benefit for recurrent disease. Furthermore, a recent consensus statement, reviewed and restated the lack of efficacy with the addition of IFN-alpha to BCG for recurrent non-muscle invasive bladder cancer. Based on current National Comprehensive Cancer Network (NCCN) guidelines for recurrent non-muscle invasive disease, patients are recommended to be retreated with BCG or intravesical chemotherapy with gemcitabine or Mitomycin. Given these findings, the requested medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer. Findings:  Three physician reviewers found the medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer.Final Result: The reviewers determined that the medication regimen consisting of BCG plus IFN combination therapy is not likely to be more beneficial than standard available therapies for treatment of this patients bladder cancer.Credentials/Qualifications: Physician reviewer 1 is board certified in oncology and is actively practicing. Physician reviewers 2 and 3 are board certified in urology 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: An enrollee has requested authorization and coverage for Nuvigil (armodafinil). The submitted documentation fails to demonstrate the medical necessity of the medication at issue. In this case, the patient reported that she has been diagnosed with narcolepsy and idiopathic hypersomnia.  Both of these diagnoses require that there be a combination of objective findings on sleep testing and exclusion of other causes of hypersomnolence undertaken by history. In this case, the patients polysomnography was negative for both narcolepsy and idiopathic hypersomnia, based on the mean sleep latency being greater than eight minutes and an absence of sleep onset rapid eye movement periods. Thus, the reported diagnoses of narcolepsy and idiopathic hypersomnia are not supported by current diagnostic standards. There is a lack of support for the medication at issue in this clinical setting. Therefore, Nuvigil (armodafinil) was not and is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

At issue is whether DecisionDx genetic test provided was likely to have been more beneficial for evaluation  of the enrollees condition than any available standard therapy. The enrollee has been diagnosed with malignant melanoma.Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. The National Comprehensive Cancer Network guidelines state that while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Newer prognostic molecular techniques should not replace standard staging procedures. This patient did not meet testing criteria for DecisionDx given the large size and positive node. The test is not used to determine the need for adjuvant chemotherapy. In sum, DecisionDx genetic test provided was not likely to have been superior over other methods of evaluating this patient.Final Result: The reviewers determined that the requested gene test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty certification in medical 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether platelet rich plasma (PRP) injections that were provided were likely to have been more beneficial for the treatment of the patients condition than any available standard therapy. He has been diagnosed with bilateral knee osteoarthritis. The complaints included pain associated with locking and instability. Previous treatments included activity modification, medication therapy, and cortisone injections. The physical examinations demonstrated a decreased range of motion, tenderness, and effusion.Two out of three physician reviewers found that the effects of PRP on knee OA are mixed, and the research is not of high quality. The majority of published data suggests better symptomatic relief with early OA. The American Academy of Orthopaedic Surgeons (AAOS) clinical practice guidelines for the treatment of osteoarthritis of the knee give an inconclusive recommendation for the use of PRP use in the treatment of knee arthritis.  An inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm. In this case, the patient is being treated for bilateral knee osteoarthritis. Review of the available literature using PRP for the treatment of knee osteoarthritis fails to demonstrate that the requested treatment significantly changes outcomes or results in better or more durable pain relief than other standard therapies. Therefore, the PRP injections provided were not likely to have been more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested treatment was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 cheek revision facial feminization surgery. The World Professional Association for Transgender Health (WPATH) Standards of Care (SOC) acknowledges that for certain patients, an intervention like a reduction rhinoplasty can have a radical and permanent effect on their quality of life, and therefore is much more medically necessary than for somebody without gender dysphoria. WPATHs SOC further states that facial feminization procedures in a patient with severe gender dysphoria can be considered medically necessary, depending on the unique clinical situation of a patients condition and life situation. Overall, facial feminization can improve the quality of life in transgender women. Social aggression and hostility towards transgender people is often based on the appearance of the person, and is mitigated by passing as the new gender publicly. The records provided for review document that this patient underwent facial feminization surgery. Postoperatively, the providers notes indicate the patient healed well and was satisfied with the outcome. However, once the post-operative swelling subsided, the patient expressed displeasure with the results. Further, the patient reports ongoing distress as a result of being misgendered within the community. The records document that this patients masculine facial features contribute substantially to her distress. Therefore, the requested cheek revision facial feminization surgery is supported as medically necessary to address this patients distress related to gender dysphoria. 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 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: At issue is whether a DaT scan is likely to be more beneficial for evaluation of the enrollees condition than any available standard therapy. The enrollee presented for a sudden onset of hand tremors. The enrollee reported symptoms to be most noticeable when performing activities requiring fine motor skills, and are lessened with drinking alcohol. Two out of three physician reviewers determined that while dopamine transporter (DaT) scans are not indicated for all patients with features of suspected parkinsonism, it has been shown to be useful in cases where the diagnosis of idiopathic Parkinson disease versus essential tremor is being considered. In some patients with suspected parkinsonian syndromes, SPECT imaging is useful to assist in the diagnosis and to help guide prognosis and treatment decisions, including avoiding medications that are unlikely to provide a benefit.  A review addresses the value of DAT-SPECT and its impact on diagnostic accuracy in movement disorders presenting with tremor and/or Parkinson disease. The authors concluded that DaT scans are helpful and sensitive to differentiate further the exact diagnosis. For this patient, the exact diagnosis is not clear. The patient does not have definitive features of either disease.  It is imperative to provide a definitive diagnosis, as a treatment for Parkinsons disease versus essential tremor are different, and placing the patient on a continued trial of dopamine therapy would place the patient at risk of significant short or long term side effects.  In this particular case, the patients care will be assisted by this study as it will help aid in the selection of future managementFinal Result: The reviewers determined that the requested diagnostic test is likely to be more beneficial for evaluation 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 board certified in neurology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for tilt table testing services. Findings:  Two of the three physician reviewers found that the medical evidence supports the services at issue in this clinical setting. This patient has a history of headaches which have been unresponsive to multiple interventions. Headaches are a common symptom associated with postural orthostatic tachycardia syndrome, especially in adolescents. Assessing this patient with recurrent persistent migraine for postural orthostatic tachycardia syndrome was appropriate based on published data. Tilt table testing is the recommended modality for diagnosing postural orthostatic tachycardia syndrome. Therefore, tilt table testing services were likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to have been more beneficial for evaluation 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 sub-specialty 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.