Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for implantation of a cranial nerve neurostimulator for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in animal and human subjects, the three and four year results of a large multicenter, prospective trial were published in January 2016 and February 2017. The STAR trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of write out (OSA). This trial has demonstrated the hypoglossal nerve stimulator to be safe and effective in a small subset of patients with obstructive sleep apnea (OSA) who have failed CPAP. With a BMI of 29, AHI of 49 and nonconcentric airway collapse at the velum, this patient meets the criteria. He has failed CPAP, which is the gold standard treatment for OSA and is at risk for untoward cardiac sequelae of untreated OSA. Moreover, this procedure is U.S. Food and Drug Administration approved and recognized by the American Academy of Otolaryngology Head and Neck Surgery. It is also recognized by the International Sleep Surgery Society. Therefore, implantation with a cranial nerve neurostimulator is likely to be more effective than the standard options available for treatment of this patients medical condition. Final Result: Two of three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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: enrollee has requested authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma and dyspnea. Findings:  The physician reviewer found that Based on the information provided, patient has mild to moderate asthma based on a forced expiratory volume-1 (FEV-1) that has been stable over the past two years and lack of reported parameters in terms of daily symptoms, limitation to exercise, nocturnal awakenings, or albuterol use. Further, the patient was not reported to have any asthma exacerbations or use of systemic steroids. Overall, the benefit shown by bronchial thermoplasty is primarily related to reduction in asthma exacerbations, use of systemic steroids, hospitalizations, and lost days of work with some mild improvement in quality of life. However, bronchial thermoplasty has not been demonstrated to result in a reduction in FEV-1. Thus, the requested bronchial thermoplasty is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the requested procedure 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a consultation and office visit with a podiatrist.  Findings:  The physician reviewer found that submitted documentation supports the medical necessity of the requested services. This patient reported left foot pain status post motor vehicle accident. The records indicated that his foot pain was affecting his ability to ambulate, causing a limp. The patient was diagnosed with foot pain, and a podiatry visit was recommended for further evaluation. The current medical evidence supports an evaluation by a podiatrist in this case. It is important that this patients foot pain is diagnosed and treated properly. All told, the requested consultation and office visit with a podiatrist is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing for evaluation of the enrollees metastatic cholangiocarcinoma.Findings:  The 2 of the physician reviewers found that found there is sufficient support for the services at issue in this patients case. Metastatic cholangiocarcinoma is a rare cancer with a poor prognosis and few effective treatment options. According to the National Comprehensive Cancer Network guidelines, trials are ongoing to evaluate systemic therapies for emerging molecular targets in hepatobiliary cancers. For patients with advanced disease, providers may wish to consider molecular profiling to determine eligibility for clinical trials of new molecular targeted agents. In this patients case, FoundationOne testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 28-year-old male enrollee has requested authorization and coverage for Cayston 75 mg/mL vial-neb for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) indications for Cayston are for patients with cystic fibrosis with a FEV-1 greater than 25% of predicted but less than 75% of predicted and who has pulmonary pseudomonas. The patient meets these criteria. The FDA approved package insert for Cayston or Tobi does not preclude rotating each drug every four weeks for pseudomonas colonization or infection. Since pseudomonas readily develop resistance, rotating Tobi and Cayston is clinically appropriate. As long as the patient does not take both Tobi and Cayston at the same time, he is taking both medications that would be consistent with the FDA approved package insert recommendations. The records indicate that this patient has followed this regimen for four years with good results. Rotating inhaled Cayston and Tobi is considered the standard of care for patients with cystic fibrosis and is consistent with the FDA recommendations for both drugs. Thus, the requested Cayston 75 mg/mL vial-neb is medically necessary for treatment of this patients cystic fibrosis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 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 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 male enrollee has requested authorization and coverage for a supervised polysomnography in a sleep laboratory for evaluation of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that in this patients case, the medical records fail to demonstrate the medical necessity of the requested services. This patient already has a diagnosis of sleep apnea. The records document that he is clinically improved on CPAP at the setting of 10 cm of water. The denial documentation noted that a home sleep study was available to the patient. There is no objective documentation that would preclude this patient from having a home sleep study.  A facility-based sleep study is not medically indicated in this clinical setting. All told, the requested supervised polysomnography in a sleep laboratory is not medically necessary for the 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 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: A enrollee has requested authorization and coverage for a supervised polysomnography in a sleep laboratory for evaluation of the enrollees sleep apnea. Findings:  The physician reviewer found that he submitted documentation fails to demonstrate the medical necessity of the requested services. There was no documentation that there was any significant weight change from the date of her prior study that would suggest she would need any other setting of CPAP.  On 7/12/17, she was alert. There is no documentation that using CPAP at 12 cm of water was no longer effective. Despite the notation that the CPAP machine exceeded its usual life span, there was no documentation that the machine was no longer effective and needed replacement as opposed to repair. The records do not support the medical necessity of another polysomnogram, either at home or at a facility. She has a diagnosis of obstructive sleep apnea, and her optimal level could be easily derived from a smartcard readout from a CPAP. All told, the requested supervised polysomnography in a sleep laboratory is not medically necessary for the 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 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: A enrollee has requested authorization and coverage for Otezla 30 mg for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the patient has plaque psoriasis who has tried and failed therapy with topical steroids. However, there is no documentation as to a treatment trial or intolerance to any of the systemic formulary medications, including methotrexate, cyclosporine, Enbrel or Humira. As there has been no prior treatment with the preferred formulary agents, the requested Otezla 30 mg is not medically necessary for treatment of this patients plaque psoriasis. 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for Foundation One gene testing for evaluation of the enrollees endometrial cancer. Findings:  The physician reviewer found that Foundation One assay explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific target which could inform the clinician as to what chemotherapeutic agent would be useful. Thus far, however, there is a lack of convincing evidence that the assay adds to the decision-making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have offered convincing evidence of the efficacy of this approach. A randomized trial by Le Tourneau and colleagues did not demonstrate significant clinical benefit from choosing therapy based on molecular assay versus by the oncologists clinical judgment. All told, Foundation One gene testing provided on 8/16/16 was not likely to more effective than other methods of evaluating this patient. Final Result: Two of three 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 reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 28-year-old female enrollee has requested authorization and coverage for facet nerve blocks, bilateral L3-L4, bilateral L4-L5, and bilateral L5-S1for treatment of the enrollees lower back pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. While this patient has some physical examination findings supporting facet joint syndrome, there is documentation of degenerative disc disease and radicular pain and radiculitis.  There is no documentation of medication trials, a home exercise program or the extent of physical therapy. The medical evidence does not support the requested services in this clinical setting.  Clinical practice guidelines which present an algorithm for the management of low back pain where there is a discogenic component, emphasize the treatment of the disc as the primary pain generator. In this case, conservative therapy has not been documented as suggested by the recent clinical practice guidelines of the American College of Physicians. All told, facet nerve blocks, bilateral L3-L4, bilateral L4-L5, and bilateral L5-S1 are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees autism spectrum disorder and mild expressive language disorder. Findings:  The physician reviewer found that in this case, the parent reports concerns for the patients speech articulation and clarity. In general, children at the age of three to four may have articulation differences with Y, Sh and other complex sounds. Based on the speech therapy evaluation, the patient is very close to his peers in expressive language and at average level for receptive language skills. In addition, all children with autism spectrum disorder do not require direct one-on-one speech therapy. 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 pediatrics with sub-specialty certification in developmental and behavioral 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.