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 Northera. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Northera is approved for the treatment of neurogenic orthostatic hypotension. The drug improves symptoms of orthostatic dizziness, lightheadedness and near-fainting. Although the records mentioned the diagnosis of orthostasis, the recorded blood pressures available for review did not demonstrate orthostasis. Autonomic function testing, which is the definitive test, did not show orthostasis. In sum, this patient does not have documented orthostatic hypotension or evidence of cardiovascular autonomic dysfunction. Therefore, Northera 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 cardiovascular 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: An enrollee has requested authorization and coverage for custom orthotics. Findings:  The physician reviewer found that initial use of basic pre-fabricated orthoses or inserts is recommended during acute phases, but with diverse anatomical differences, some patients may subsequently require a custom made orthosis. The medical literature concludes there is no high-level evidence supporting the use of foot orthoses for flexible pes planus. Per the authors, there is good to moderate level evidence that foot orthoses improve physical function (medial-lateral sway in standing (level II) and energy cost during walking (level III)). There is low level evidence (level IV) that foot orthoses improve pain, reduce rearfoot eversion, alter loading and impact forces; and reduce rearfoot inversion and eversion moments in flexible pes planus. Well-designed randomized controlled trials that include appropriate sample sizes, clinical cohorts and involve a measure of symptom change are required to determine the efficacy of foot orthoses to manage adult flexible pes planus. This patient presents with a history of bilateral foot pain. He is status post left great toe arthroplasty and right first metatarsophalangeal joint cheilectomy. The records suggest he has been diagnosed with pes planus, and he has utilized foot orthotics on a long-term basis. In this case, there is no current documentation of a left foot examination. There is no clear documentation of a current foot condition that would support the use of a custom orthotic over pre-fabricated orthoses or inserts. There is no documentation that the current orthotics are broken or worn out to require replacement. Therefore, the requested custom orthotics are not medically necessary for the treatment of this patient. 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 orthopedic suregry 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 Orencia. This patient with minimal change disease has reportedly failed treatment with mycophenolate and could not tolerate calcineurin inhibitors (CNIs). Studies noted that minimal change disease is a major cause of idiopathic nephrotic syndrome (NS), characterized by intense proteinuria leading to edema and intravascular volume depletion. However, the medical literature does not support a role for Orencia in the treatment of minimal change disease. Ongoing studies are being conducted to establish the efficacy and safety of Orencia in the treatment of minimal change disease. Therefore, the requested Orencia is not supported as medically necessary for treatment of this patients minimal change disease. 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 nephrology 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 the stab phlebectomy of varicose veins procedure is likely to be more beneficial for the treatment of the patients condition than any available standard therapy. The patient presented with complaints of ongoing pain in the right leg, inability to stand, and associated itching. Prior treatments included greater than three months of compression stockings, elevation, exercise, and medication therapy. She was diagnosed with chronic venous hypertension with inflammation of the right lower extremity.Findings:  Two out of three physician reviewers found that there is evidence to support the requested the stab phlebectomy of varicose veins procedure. The Society for Vascular Surgery (SVS) and the American Venous Forum (AVF) have developed clinical practice guidelines for the care of patients with varicose veins of the lower limbs and pelvis. In this case, the rationale for not treating the great saphenous vein is that it is too small and that even with reflux, it is likely to have no clinical impact. With clinically-irrelevant reflux, only removing the branches is required. One out of three physician reviewers found that most data show that there are advantages of up to two years with either laser or radiofrequency ablation compared to standard stripping and there is a greater patient acceptance with shorter recovery time. Thus, the stab phlebectomy of varicose veins procedure is not likely to be more beneficial for the treatment of the patients condition than any available standard therapy.Final Result: Two out of three reviewers determined that the requested procedure 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 vascular 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: Upheld Decision of Health Plan

The patient has requested authorization and coverage for total abdominal hysterectomy. The American College of Obstetricians and Gynecologists (ACOG) recommends use of non-steroidal anti-inflammatory drugs (NSAIDs), oral contraceptives, and intrauterine devices for the treatment of menorrhagia. The ACOG specifically noted that surgical management should be considered for patients who are not clinically stable, are not suitable for medical management, or have failed to respond appropriately to medical management. Surgical intervention can include endometrial ablation or vaginal hysterectomy or total laparoscopic hysterectomy with or without bilateral salpingectomy. Current medical literature indicates that minimally invasive surgery is associated with a lower complication rate for well selected patients. This patients records document prior treatment has included medroxyprogesterone. However, the documentation does not demonstrate that first-line therapies have failed to provide the patient with sufficient symptomatic improvement. The patient has not exhausted standard treatment with NSAIDs, oral contraceptives, or an intrauterine device prior to consideration for surgical intervention. Therefore, the requested total abdominal hysterectomy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether the perirectal spacers used during prostate radiotherapy that was performed were likely to have been more beneficial for treatment of the patients condition than any available standard therapy. The records indicate that the patient was diagnosed with malignant neoplasm of the prostate and adenocarcinoma. He underwent placement of a fiducial marker and absorbable perirectal implant for radiotherapy. Findings:  Three physician reviewers found that current published evidence in the peer-reviewed medical literature supports the use of perirectal spacers to improve health outcomes in patients with prostate cancer undergoing radiotherapy. In clinical trials, this benefit has translated into decreased long-term rectal toxicity, decreased urinary incontinence, and better sexual function. Overall quality of life was also better in patients who had the perirectal spacers placed during prostate radiotherapy. The National Comprehensive Cancer Network (NCCN) supports perirectal spacers in the national guidelines for the management of prostate cancer. Final Result: The reviewers determined that the perirectal spacers was 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for a breast magnetic resonance imaging (MRI) that was provided. The Health Plan has denied the service at issue as investigational or experimental for evaluation of the enrollees breast health.Findings:  Two out of three physician reviewers found that contrast enhanced breast MRI is more sensitive for the detection of breast cancer in the high-risk population, approximately 90 percent sensitive, than both mammography and ultrasound, approximately 38 percent individually. Screening breast MRI is recommended in patients with a lifetime risk of greater than 20 percent, patients with BRCA gene mutations and their untested first-degree relatives as well as other high-risk populations. The American Cancer Society, American College of Radiology, and Society of Breast Imaging all recommend annual screening MRI in high-risk patients. In this case, the patients calculated lifetime risk of breast cancer is above 20 percent, and therefore, breast MRI is indicated. Screening mammography is also recommended, although the patient defers at this time. Thus, the breast MRI that was provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One physician reviewer found that the breast MRI that was provided 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 service at issue was 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 diagnostic radiology 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:At issue is whether the MRI of the breast that was provided likely to have been more beneficial for the evaluation of the enrollees condition than any available standard therapy. The enrollee presented to her provider with complaints of waking up from pain. She is status post silicone breast augmentation and subsequent cellulitis. The plan of care was to repeat laboratory evaluations and obtain a breast MRI.Findings:  Three physician reviewers found that the medical literature indicates that for evaluation of possible breast implant rupture, an MRI is the most sensitive and specific imaging test available for such evaluation and far exceeds standard mammography and ultrasound in this capacity. This patient had a history of post-operative left breast cellulitis and, therefore, has a risk of other complications. Based upon the concern of complications the MRI that was done was the most appropriate test for this patient.Final Result: The reviewers determined that the requested MRI 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 diagnostic radiology 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 was diagnosed with type 2 diabetes mellitus. Laboratory results indicated that the patients blood glucose level was 134 and the hemoglobin A1c level was 6.8%. It was noted the patient had been following a diabetic diet and had been taking metformin and glipizide. No polyuria, polydipsia, or significant weight changes were noted. The patient has requested coverage for a non-formulary exception for One Touch Verio Flex strips for glucose testing. The Health Plan denied the request and reported the requested equipment is not medically necessary for the evaluation of this patient. At issue in this case is whether non-formulary One Touch Verio Flex strips for glucose testing are medically necessary for the evaluation of the enrollees medical condition. The availability of accurate tools, including a meter and test strips, for self-monitoring of glucose levels allows the patient to stay on course with glucose fluctuations related to diet, physical activity and illness (ADA). In this case, the health plan has made available a different brand of meter and glucose test strips, Accu-Chek. The Accu-Chek brands, Aviva Plus and Smartview, are superior to the Lifescan's One Touch Verio and Ultra2 brands. The Diabetes Technology Society (DTS) Blood Glucose Monitor System (BGMS) Surveillance Program published a study that assessed the accuracy of 18 BGMS marketed in the U.S. across a wide range of blood glucose levels. The 18 BGMS represented approximately 90% of the commercially available systems that were used from 2013 to 2015 by diabetes patients. The Lifescan One Touch Verio passed two of three studies and did not receive a seal of approval from the DTS. The Accu-Chek Aviva and Smartview brands passed all studies and received the seal of approval from the DTS. The One Touch Verio brand was not superior to the Accu-Chek brand in a triple blinded study of 18 meters. Therefore, the requested non-formulary exception for One Touch Verio Flex strips for glucose testing is not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in endocrinology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue is whether genetic testing that was received was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The patient had a history of right breast carcinoma and was status post right lumpectomy and axillary node dissection. She was treated with chemotherapy and radiation therapy. The patient subsequently underwent radiation therapy to the spine and to the lung mass.Findings:  Two out of three physician reviewers found that applying the National Comprehensive Cancer Network (NCCN) guidelines, this patient meets criteria for genetic testing due to being diagnosed with a breast cancer before age 50 and having metastatic disease. Genetic panel testing is now considered a standard of care. Carrying a mutation will guide screening, prognosis, as well as treatment decisions. One out of three physician reviewers found that in this case, the testing included a full 25 gene panel, which includes BRCA testing and several others. The additional genes included in this panel were not likely to have been of clinical benefit to this patient.Final Result: Two out of three medical experts determined that the requested genetic testing was 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 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 apolipoprotein assay (CPT code 82172) performed was likely to have been more beneficial for the evaluation of the patients condition than any available standard therapy. The records documented a diagnosis of lung cancer. The provider documented concern for metastasis to the liver.Findings:  Three physician reviewers found that there is very little data relating this assay to the treatment or prognosis of cancer. Apolipoprotein levels have been studied for their relationship and prognostic ability for cerebrovascular accident (CVA), atherosclerosis, and myocardial infarction.   It is not clear why this test was ordered during the workup of possible liver metastases. Therefore, apolipoprotein assay (CPT code 82172) performed was not likely to have been more beneficial for evaluation of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: At issue in this case is whether the requested Norco is medically necessary for the treatment of the patients medical condition. The patient has a history of bilateral common iliac artery aneurysms and chronic pain related to vascular claudication.  Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain such as documentation of an opioid risk assessment, including risk of substance use, ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. The records do not document that different types of other therapies have been exhausted, despite significant research to support their use. Finally, not all non-opioid medication classes have been optimized or tried. The submitted documentation fails to demonstrate the medical necessity of the requested medication. 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 with a sub-specialty 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.