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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Lo Loestrin Fe. The use of oral contraceptive pills to mediate the symptoms of perimenopause and medical problems has been supported. This patient has shown improvement in her multiple sclerosis symptoms with the use of low dose oral contraceptive pill.  Given that the patient is approaching the age of menopause, the short-term use of the oral contraceptive pill is reasonable. This patient has demonstrated that a higher dose of estrogen is not tolerated, as it caused an elevation in her blood pressure. In general, the lowest dose of estrogen should be used that is therapeutically effective. Thus, Lo Loestrin Fe is 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 obstetrics and gynecology 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 advanced lipoprotein testing. Findings:  Three physician reviewers found guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Entyvio once every four weeks. The patient has objective evidence of disease activity after initial response to Entyvio therapy. Continuation of Entyvio every eight weeks, or a change to an alternative therapy, may result in worsening disease or disease complications such as disease flare, fistula, stricture, need for hospitalization, or need for additional surgery. For these reasons, Entyvio once every four weeks is supported as medically necessary for the treatment of this patients Crohns disease.Final Result: The reviewer determined that the requested medication dosage 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. Further, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.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: A patient requested authorization and coverage for tadalafil (Cialis). The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients benign prostatic hyperplasia. The submitted documentation does not support the medical necessity of the requested medication. Phosphodiesterase type 5 (PDE5) inhibitors such as Cialis (tadalafil) have been studied in men with BPH/LUTS. The efficacy of tadalafil for BPH/LUTS is based on findings that show the expression of the PDE5 enzyme in the lower urinary tract, which include (prostate, bladder, urethra and, vascularity). PDE5 inhibition results in smooth muscle relaxation and may increase pelvic blood perfusion, which is suspected to affect smooth muscle tone. Clinical studies on the efficacy and safety of therapy with tadalafil demonstrated that tadalafil leads to statistically significant improvements in IPSS symptom scores as early as one to two weeks after beginning therapy. Improvements in total IPSS that occurred over the initial 12 weeks of tadalafil treatment were maintained over a one-year, open-label extension period. The standard of care for treatment of patients with BPH includes alpha-blockers and 5 alpha reductase inhibitors. Studies comparing alpha-blockers and daily tadalafil used as monotherapy have failed to prove the superiority of daily tadalafil over alpha-blocker therapy. Accordingly, tadalafil (Cialis) 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the services at issue. Medical guidelines for eating disorders recommend that the standard of treatment is either an inpatient unit or residential treatment facility when lower levels of care have been tried and failed, and further that the presence of comorbid conditions is an important factor to be considered when deciding on a level of care. A study conducted of treatment results of anorexia nervosa and bulimia nervosa in a residential treatment program noted that for patients with anorexia nervosa (AN), there were statistically significant improvements in mean BMI. In addition, for both AN and bulimia nervosa patients, there were statistically significant improvements in Beck depression inventory (BDI) scores, all 11 eating disorder inventory (EDI)-2 subscales, and frequencies of bingeing, vomiting, laxative abuse, chewing and spitting, stimulant abuse, and restricting behavior. The great majority of patients completing treatment showed significant improvement at discharge from intensive residential treatment. In this case, the patient was experiencing a disturbance in mood, affect, or cognition resulting in disordered eating behavior that could be safely managed in a less restrictive setting. Thus, residential treatment was in accordance with generally accepted standards of medical practice, clinically appropriate for the patient's illness, not more costly than an alternative service for treatment of the patients condition, and was therefore medically necessary. Accordingly, the residential treatment center 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 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 Climara 0.075 mg per 24 hours transdermal patch. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records do not document that this patient has failed the currently available estrogen replacement options that are offered. Although Climara is helping the patient with her menopausal symptoms, the alternative medications offered by the Health Plan are reasonable. These alternative medications are likely to help relieve her symptoms, and she may likely not have similar side effects. Therefore, Climara 0.075 mg per 24 hours transdermal patch 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 obstetrics and gynecology 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 Afrezza (insulin powder inhaler). Afrezza is a rapid-acting Technosphere insulin administered via a breath-powered oral inhaler to patients with diabetes requiring prandial insulin (Gala). Although Afrezza achieved the prespecified non-inferiority margin of 0.4% as compared to injections of rapid acting insulin in a recent trial, patients with type 1 diabetes who received Afrezza demonstrated less reduction in hemoglobin A1c levels. Based on the available documentation, there is a lack of support for use of Afrezza for this patient in lieu of injectable insulin, which is considered the standard of care in this clinical setting. For these reasons, the requested Afrezza (insulin powder inhaler) is not supported as medically necessary for treatment of this patients type 2 diabetes.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 endocrinology, diabetes and metabolism 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 Cosentyx pen injector. The submitted documentation supports the medical necessity of the requested medication. In this case, the patient has failed treatment with methotrexate, Otezla and Humira.  The medical evidence supports a trial of an interleukin-17 inhibitor like Cosentyx after a failure of methotrexate and a tumor necrosis factor inhibitor. The patient has responded well to this therapy and has no active synovitis or skin lesions. Therefore, Cosentyx pen injector is 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 rheumatology 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 DecisionDx-Melanoma Gene Assay testing. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion measuring 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision but they suggest a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha. However, the current data on the DecisionDx-Melanoma Gene Assay does not support its use as part of routine analysis after sentinel lymph node biopsy. Thus, the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the DecisionDx-Melanoma Gene Assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Apokyn injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients Parkinsons disease. The submitted documentation supports the medical necessity of the requested medication. Studies show that motor fluctuations are common and distressing for patients with advanced Parkinson's disease. Subcutaneous apomorphine injections were noted to be an extremely valuable adjunctive therapy, given that it helped with motor fluctuation symptoms due to off periods. Studies recommended that Apokyn was clinically helpful for treatment of motor fluctuations. The available clinical studies indicate that apomorphine, also known by the brand name Apokyn, is effective in providing prompt and consistent rescue from `off` episodes in patients with Parkinsons disease. The medical records submitted for review document findings consistent with motor fluctuations due to Parkinsons disease. Motor fluctuations due to off periods can only effectively be treated with Apokyn. As such, Apokyn injections are medically necessary at this time for the treatment of this patient.Final Result: The reviewer determined that the 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aptiom 800 mg, two pills daily for treatment of the enrollees focal epilepsy. Findings:  The physician reviewer found that a seizure is an uncontrolled electrical disturbance in the brain that can cause neurological symptoms that affect behavior, movements, and levels of consciousness. This patient has been diagnosed with focal epilepsy. There are several U.S. Food and Drug Administration (FDA) approved medications that are designed to manage partial epilepsy. However, there is a lack of evidence supporting the superior efficacy of Aptiom compared with other covered antiepileptic drugs offered by the Health Plan.  There is no documentation that the patient failed or has a contraindication to other medications covered by the Health Plan. Additionally, the active ingredient in Aptiom is equivalent to other medications currently covered by the Health Plan. Therefore, Aptiom 800 mg, two pills daily 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 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: An enrollee has requested authorization and coverage for Trintellix 30 mg (Trintellix 20 mg to use together with Trintellix 10 mg). Trintellix has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of major depressive disorder. This medication is typically dosed between 10 to 20 mg daily, and there are no appreciable studies of supra-therapeutic dosing in the peer-reviewed medical literature. In this patients, the current dose of Trintellix was achieved in late 2017 after a systematic titration targeting flat mood, poor motivation and lack of passion. By February 2018, the patients mood was improved, and he was consuming less alcohol. Per the records, the current medication dose appears to be both efficacious and well-tolerated, with no evidence of side effects or safety concerns. The treatment is optimizing functionality and minimizing the illness burden. There is sufficient support for the requested medication regimen in this patients case. Therefore, Trintellix 30 mg (Trintellix 20 mg to use together with Trintellix 10 mg) is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: enrollee has requested authorization and coverage for tertiary level of care. Multiple sclerosis is a progressive immune disease affecting the central nervous system, causing neurological dysfunction. Multifocal inflammation of the central nervous system characterizes the disease and causes impaired nerve conduction. Multiple sclerosis care can be provided in many different clinical settings. This patient is currently under care for her multiple sclerosis by a community neurologist. The neurological care as documented by the provider can continue to be provided in the community. The Health Plan has provided a neurologist within a reasonable radius. Therefore, the requested tertiary level of care is not medically necessary for the treatment of this patient.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 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.