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 Saxenda for treatment of the enrollees chronic weight management. Findings:  The physician reviewer found that Saxenda is approved by the U.S. Food and Drug Administration as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition, such as hypertension, type 2 diabetes mellitus, or dyslipidemia. The recommended approach to weight loss with pharmacological management of obesity is for a patient to receive counseling on diet, lifestyle and goals for weight loss. Medications such as Orlistat are considered first line treatment.  Saxenda is an alternative option for overweight or obese patients with type 2 diabetes mellitus. The patient is documented as weighing 170.2 pounds and is 63.5 inches tall with a resulting BMI of 29.7.  The laboratory studies that were performed on 5/26/16 noted normal glucose and cholesterol levels with an HgbA1C at 5.7. 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 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 magnetic resonance imaging (MRI) of the chest (with and without contrast) for evaluation of the enrollees mass lesions and localized swelling on his chest. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. The American College of Radiology (ACR) has established the appropriateness criteria in the category of chronic chest pain where it is unlikely that the pain is cardiac but where pleural disease is a consideration. Per the ACR guideline, MRI has the next to lowest appropriateness rating (2 out of 9). The medical studies and guidelines do not support that MRI of the chest will contribute to the diagnosis or management of the patients medical condition. In this patients case, the areas of the costochondral junctions were specifically evaluated. The laboratory workup, including studies to evaluate for rheumatologic diseases, was negative. This patient has multifocal, aligned, and symmetric symptoms for as long as two years. This clinical presentation, as noted by the referring physician, is not suggestive for occult malignancy. The likelihood that these multifocal masses are neoplastic is low. The best means to evaluate these types of signs and symptoms is through a CT scan of the chest which the patient underwent in June 2016. For these reasons, the requested coverage for magnetic resonance imaging (MRI) of the chest (with and without contrast) is not medically necessary for evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 Tylenol #3 for treatment of the enrollees chronic pain. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Per the submitted documentation, the patient has not been physically examined by a physician in several months and she has not kept recent office appointments.  The standard of care requires that a provider take a history and personally examines a patient before prescribing narcotics.  Since the patient has not kept her appointments, it is not medically appropriate to prescribe narcotics.  There is a lack of support for the requested medication in this clinical setting.  All told, Tylenol #3 is not medically indicated 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 anesthesiology with sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary.  An enrollee has requested Novacure-Optune tumor treating fields (TTF) for treatment of the enrollees glioblastoma.   Findings: Three physician reviewers found that the patient is diagnosed with glioblastoma multiforme (GBM). The patient was diagnosed in and treated with surgical resection followed by radiation in combination with temozolomide. A follow-up magnetic resonance imaging showed possible progression versus radiation necrosis. The patients provider recommended treatment with Novacure-Optune tumor treating fields (TTF) as maintenance therapy in combination with temozolomide. The Health Plan has denied this requested device as investigational for treatment of this patient. There is sufficient medical evidence supporting Novacure-Optune TTF therapy, also known as alternating electric field therapy, for treatment of patients diagnosed with GBM.  The National Comprehensive Cancer Network has endorsed TTF therapy as maintenance therapy along with temozolomide in patients with supratentorial lesions, as in this patients case.  Moreover, the device is approved by the U.S. Food and Drug Administration for use in maintenance therapy after primary treatment is completed. The patient was treated with surgical resection followed by radiation therapy. Therefore, Novacure-Optune TTF therapy is likely to be more beneficial than existing therapies for treatment of this patient. Final Result: Three physician reviewers have determined that the requested device 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: All three physician reviewers are board certified in internal medicine 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intravenous antibiotic (Rocephin 2 g daily x 30 days) for treatment of the enrollees diagnosis of Lyme disease. Findings: Three physician reviewers found that the diagnosis of neuroborreliosis is based on three factors, the possibility of Ixodes tick bite, clinical neurological disorders consistent with nervous system Lyme disease, and laboratory testing to support infection. In this case, the patient was reportedly bitten by a tick in an area known to have Ixodes ticks and Borrelia burgdorferi. Although bitten, it is unclear by what type of tick and if the time was sufficient for transmission of the spirochete. She did not have the characteristic erythema migrans (EM) rash. She does have a history of facial hemiplegia and persistent spasms. According to the Centers for Disease Control and Prevention (CDC), these findings are considered a cranial neuropathy which typically occurs early in the disease process and these patients have high antibody titers to Lyme. This patient does not does not have evidence of high antibody titers to Lyme. A two-tiered serological testing is recommended by the CDC for the diagnosis of Lyme disease which was performed and was negative. She also does not fulfill the serologic criteria as she has a negative Lyme titer, negative Western blot and negative CSF evaluation. She has a single band of IgG and IgM on Western blot, but five bands are required in order to be considered positive (Dressler, et al). Although she complains of current facial spams and joint achiness, her examination is otherwise unremarkable. At this time, the records fail to demonstrate that the patient has neuroborreliosis. For these reasons, the requested intravenous antibiotic (Rocephin 2 g daily x 30 days) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested medication 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:All three physician reviewers are board certified in internal medicine with sub-specialty certifications in allergy and immunology and rheumatology 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 Sovaldi and Daklinza for 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen.  According to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, for treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen.  Furthermore, delay in treatment may result in decreased survival.  All told, the requested medication regimen of Sovaldi with Daklinza for 12 weeks 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of the enrollees hip pain.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested medication. There is limited peer-reviewed literature supporting Supartz injections for the treatment of osteoarthritis of the hip. Migliore and colleagues noted that sodium hyaluronate ultrasound guided injection seemed to delay total hip replacement in the context of overall management of symptomatic hip osteoarthritis patients. The authors concluded that Although further studies are necessary to confirm these data and to identify outcome predictors, hip viscosupplementation should be considered as conservative treatment to perform before proposing patients for hip replacement. Legre-Boyer indicated that results with viscosupplementation have been generally disappointing in hip osteoarthritis, but promising in osteoarthritis of the ankle and shoulder. The author concluded that Further studies are needed to determine response profile and optimal treatment schedule, according to the joint. In this case, the patient presented with a two-month history of left hip pain following lunging activity. He reported significant pain that interfered with sleep and was no longer responding to anti-inflammatory medications. Clinical exam findings were consistent with femoroal acetabular impingement and highly suggestive of a labral tear. X-rays showed evidence of moderate osteoarthritis of the left hip. However, there is a lack of evidence demonstrating that conservative treatment beyond anti-inflammatory medications and activity modification have been tried and failed. Given the absence of a comprehensive conservative treatment trial including the recommended physical therapy and the lack of support in the peer-reviewed literature, Supartz injections have not been established as medically necessary for treatment of the patients medical condition.  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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi with ribavirin for 12 weeks for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. The guidelines recommend treatment with Sovaldi/Daklinza or Epclusa for treatment-naive, genotype 2 patients.  The medication regimen of Sovaldi and ribavirin is no longer recommended.  The guidelines cite data showing that delay in treatment may result in decreased survival. For these reasons, although hepatitis C treatment is necessary, the requested medication regimen of Sovaldi and ribavirin for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis that was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure 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: All three physician reviewers are certified in diagnostic radiology and is actively practicing. The reviewers are expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent an enrollee has requested authorization and coverage for speech therapy once a week for treatment of the enrollees speech delay. Findings:  The physician reviewer found that in this patients case, the records show that she has severe deficits in speech and language skills, as well as pragmatic language skills. This is complicated by the potential diagnosis of selective mutism. According to the current standard of care, speech therapy is medically necessary and appropriate. This patient has made progress with weekly intervention and active parent support. Although decrease in individual therapy sessions to twice monthly was recommended, the documentation from April 2016 supports good progress with the current weekly therapy sessions and active parent participation. Ongoing weekly therapy is medically appropriate. A decrease in intervention may result in loss of progress and regression, negatively impacting her ability to effectively communicate her wants and needs and provide age appropriate peer interactions. The medical literature show that the sooner and more aggressively these deficits are targeted, the better chance the child has for developing adequate skills to function in the community. Final Result: The reviewer determined that requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1b.  Findings: The physician reviewer found that 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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: An enrollee has requested C2, C3 and C4 medial branch rhizotomy for treatment of the enrollees cervical facet arthropathy. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Manchikanti and colleagues reviewed the effectiveness of medial branch blocks in systematic reviews and randomized trials. Thoracic spine was noted to have evidence with controlled blocks Level II-1, moderate to strong evidence lasting from months to a year with level II-2 to II-3. Thoracic facet joint nerve blocks showed improvement in 71% of the patients at six months, 76% at 12 months, 71% at 24 months, and 69% at 36 months. In addition, Son and colleagues found that repeated radiofrequency ablation for lumbar facet syndrome provides successful pain relief for about 10 months in more than 85% of carefully selected patients. In this case, the patient states he received up to 10 months of relief with a prior rhizotomy. However, the medical records do not adequately document the nature of the patients neck pain or document that the patient has been treated with a prior rhizotomy 10 months prior. Given the lack of documentation demonstrating that previous rhizotomy has been performed, the request for C2, C3 and C4 medial branch rhizotomy has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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.