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 Everolimus 5 mg, 30 tablets per month. This patient presents with recurrent glioblastoma. Per the provider, the patient has been treated with resection and chemotherapy including a clinical trial with nab-rapamycin at 60 mg per day, at least six weeks of radiation with temozolomide, and four cycles of adjuvant treatment with nab-rapamycin and temozolomide. The patients provider has recommended treatment with everolimus given the patients recurrence. Everolimus is not U.S. Food and Drug Administration (FDA) approved for the treatment of glioblastoma. Moreover, current major drug compendia and the National Comprehensive Cancer Network (NCCN) guidelines does not recommend treatment with everolimus for patients with recurrent glioblastoma (Nabors, et al.). The use of everolimus has been studied in patients with lower grade tumors, such as subependymal giant cell astrocytoma, but not glioblastoma which is a high grade tumor. A phase II trial of everolimus in recurrent glioblastoma failed to show efficacy (Cloughesy, et al.). Therefore, the requested Everolimus 5 mg, 30 tablets per month 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a peroral endoscopic myotomy (POEM) procedure. Findings:  The physician reviewer found that the management of gastroparesis involves correcting fluid, electrolyte and nutritional deficiencies, identifying and treating the cause of delayed gastric emptying such as diabetes mellitus, and suppressing or eliminating symptoms with pharmacological agents as first-line therapies. Bharucha and colleagues report that initial options for the management of diabetic gastroparesis include dietary modifications, supplemental oral nutrition, and antiemetic and prokinetic medications, and for patients with more severe symptoms, a venting gastrostomy or jejunostomy and/or gastric electrical stimulation. In this case, the patient has a history of diabetic gastroparesis with nausea, vomiting, bloating and early satiety. There is a lack of evidence in current medical literature that the requested POEM procedure would result in improved health outcomes over conventional therapies such as lifestyle modifications along with medical therapy. Therefore, the requested POEM procedure is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested peroral endoscopic myotomy (POEM) procedure 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 service is 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 internal medicine with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for EsophyX transoral incisionless fundoplication (TIF) surgery (CPT 43210). This patient presents with a history of GERD. The provider noted that the patient has failed standard treatment with proton pump inhibitor (PPI) medications. The provider has recommended the EsophyX TIF procedure. The efficacy of TIF has been studied in randomized controlled trials (Trad). However, the conclusions are contradictory (Witteman, et al.). The 2013 American College of Gastroenterology (ACG) guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (Katz, et al.). Auyang and colleagues found that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for patients with complicated GERD, which the guideline defines as dysphagia or Barretts esophagus and report that the long-term follow-up data for TIF are limited. Therefore, the requested EsophyX TIF surgery (CPT 43210) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the requested EsophyX TIF surgery (CPT 43210) 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high intensity focused ultrasound (HIFU). This patient presented with Gleason score 3+4=7 prostate cancer. Findings:  The physician reviewer found that data suggesting fewer risks for urinary incontinence and erectile dysfunction. HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. HIFU has been increasingly used for treatment of localized prostate cancer over the last decade. However, there is a lack of controlled trials available for analysis, and a paucity of long-term survival data are available. The National Comprehensive Cancer Network (NCCN) guidelines state that the panel recommends only cryosurgery and HIFU as options for radiation therapy recurrence in the absence of metastatic disease. The National Cancer Institute (NCI) does not include HIFU as one of the seven standard treatments for treatment of prostate cancer, rather it is classified under new types of treatments that are being tested in clinical trials. Furthermore, the American Society of Radiation Oncology (ASTRO) does not endorse HIFU in the treatment of or patients with prostate cancer. Therefore, the HIFU was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Findings:  Three of the three physician reviewers found the HIFU was 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 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: Physician reviewers 1, 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a bone growth stimulator. The records provided for review document that this patient has sustained an injury to her left fifth toe. X-rays demonstrated fracture through the conjoint phalanx of the fifth toe without significant displacement. Physical examination revealed no appreciable swelling around the forefoot or fifth toe. The patients provider has recommended a bone growth stimulator. Electrical stimulation has been used as an adjunct for treatment of nonunion in an effort to achieve bony healing of surgical fusions. There is paucity of peer-reviewed medical literature to support the routine use of a bone growth stimulator in the setting of toe fracture with delayed union. Typically, a fracture is considered to have gone on to nonunion six months following injury. The adjunctive use of a bone stimulator is only considered with no evidence of progressive healing on sequential imaging studies. In this case, the two imaging studies discussed included x-rays and computed tomography (CT) scan, which reportedly demonstrated healing with partial osseous bridging. Overall, there is a lack of scientific evidence to suggest a bone growth stimulator would be more beneficial than any available standard treatment for this patients left fifth toe phalanx fracture. All told, the requested bone growth stimulator (E0747) 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 bone growth stimulator (E0747) 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 reviewer 1 is board certified in orthopedic surgery with expertise in hand surgery and sports medicine and is actively practicing. Physician reviewer 2 is board certified in orthopedic surgery and is actively practicing. Physician reviewer 3 is board certified in orthopedic surgery and is 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 pregabalin 75 mg, two tablets a day.The use of gabapentin, another related gamma aminobutyric acid (GABA) analog, is recommended by American College of Chest Physicians for the management of unexplained cough, not mediated by asthma, eosinophilic/allergic processes, upper airway cough syndrome, or gastroesophageal reflux. Additionally, according to Vertigan and colleagues, pregabalin was effective in treating chronic refractory cough in a randomized trial in which 40 adults were assigned to take pregabalin with speech pathology treatment (SPT) or placebo with SPT. Moreover, the use of gamma aminobutyric acid analogs (including pregabalin) for the treatment of chronic refractory cough, particularly when providers suspect a central mechanism, is standard practice in pulmonary medicine and often highly effective in curbing or eliminating debilitating cough syndromes. In this case, the patient has a chronic cough that has not been successfully treated with other medication. Additionally, testing has eliminated other causes for the cough. The records show that the patient has shown improvement while taking pregabalin. Thus, the requested pregabalin 75 mg, two tablets a day, is medically necessary for the treatment of the patients medical condition.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 pulmonary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Amitiza (lubiprostone). The American Gastroenterological Association (AGA) guidelines on the medical management of opioid-induced constipation states, The panel favored use of a combination of at least two types of laxatives before escalating therapy, and also that scheduled use of laxatives (versus use as needed) is required before determining whether alternative opioid-induced constipation therapy is necessary. Further, the guidelines do not specifically recommend the use of Amitiza, stating, The AGA makes no recommendation for the use of lubiprostone in the treatment of opioid-induced constipation, due to an evidence gap.  In this case, given the records do not document the patient has failed first-line treatment with a laxative regimen, and based on available guidelines on the treatment of opioid-induced constipation, the requested medication is not medically indicated. Therefore, Amitiza (lubiprostone) 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 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: An enrollee has requested authorization and coverage for Orthovisc injection series in both knees.Findings: An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history of long-term relief from viscosupplementation of both knees with Orthovisc for the last 10 to 15 years. Furthermore, the options are limited, with the alternative being bilateral total knee arthroplasties. Thus, the requested Orthovisc injection series in both knees is medically necessary for the treatment of the patients medical condition.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 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 Euflexxa injection series in the knee.An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the options are limited. The patient has tried and failed other conservative treatments, with the alternative being a total knee arthroplasty for mild to moderate osteoarthritis. Thus, the requested Euflexxa injection series in the knee is medically necessary to treat the patients medical condition.Final Result: The reviewer determined 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lymphovenous bypass surgery Findings:  The physician reviewer found that medical literature supports the use of lymphovenous bypass surgery in reducing the severity of the symptoms of lymphedema. Schaverien and Coroneos note that lymphedema may result in long-term disability and functional impairment that may be ameliorated by lymphovenous bypass procedures. Chang and colleagues report that lymphovenous bypass can be effective in reducing lymphedema severity. In this case, in a letter dated 12/8/20, the provider reported that the patient had a progressive history of worsening right lower extremity primary lymphedema and was compliant with conservative therapy, including compression, pump, manual lymphatic drainage, and elevation. The patient was status post lymphovenous bypass surgery in December 2019 with great improvement. The provider recommended a repeat lymphovenous bypass procedure for continued control of symptoms, reporting that left untreated, lymphedema could lead to cellulitis, sepsis, disability, and even death, along with significant disability. In this clinical setting, given the failure of conservative measures in controlling the patients symptoms, and the patients improvement following his first surgery, the providers recommendation for a repeat lymphovenous bypass surgery is supported. Therefore, the requested lymphovenous bypass surgery  is likely to be more beneficial for treatment of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the lymphovenous bypass surgery 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 service 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 is board certified in surgery and in plastic surgery and is actively practicing. Physician reviewers 2 and 3 are board certified in plastic 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 Otezla 30 mg.The current medical evidence supports the medical necessity of the requested medication. Otezla is a safe and efficacious treatment that has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of psoriasis. This medication has been demonstrated to be efficacious in this clinical setting. Otezla (apremilast) is recommended for the treatment of moderate to severe psoriasis in adults. It receives an `A` grade from the joint National Psoriasis/American Academy of Dermatology guidelines on the treatment of psoriasis. In this case, the patient has been diagnosed with plaque psoriasis. Additionally, the patient has tried and failed treatment with topical corticosteroids. Therefore, Otezla 30 mg is medically necessary for the treatment of the patients medical condition.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 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.