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 Humira 40mg subcutaneously every 2 weeks. The Health Plan has denied this request indicating that the requested treatment is not medically necessary for treatment of the enrollees psoriasis. A review of the record indicates that the enrollee has been diagnosed with lichen planus, and psoriasis. In a report the enrollees provider noted worsening psoriasis with lesions over the scalp, elbows, and shins. The provider noted Enbrel was discontinued due to hair loss. The enrollee had also been treated with methotrexate, Otezla, Cellcept, and prednisone. The enrollees provider has recommended Humira 40mg/0.8ml subcutaneously every 2 weeks #2 for the enrollee.Humira (adalimumab) is a fully human tumor necrosis factor alpha (TNF-alpha) monoclonal antibody approved for the treatment of rheumatoid arthritis which is also used in treating other conditions, including psoriasis and psoriatic arthritis. Open prospective studies and randomized controlled trials have shown the short-term efficacy of adalimumab in psoriatic arthritis and psoriasis. Adalimumab has been shown to be effective therapy when used either continuously or intermittently at 40 mg subcutaneous injections every other week. In cases resistant to conventional dose, the efficacy of adalimumab can be increased by dose escalation, such as shortening the dosing interval and increasing the amount of medication per single dose. In a multicenter, randomized, double blind, placebo-controlled study, 147 psoriasis patients received adalimumab (40 mg every other week or 40 mg/week) or placebo. After 12 weeks of blinded therapy, patients taking adalimumab could continue their assigned dosages in a 48-week extension trial; patients taking placebo were switched to adalimumab (40 mg every other week). The results demonstrated patients taking adalimumab showed improvement in their psoriasis symptoms. The records documented subjective and objective findings consistent with the diagnosis of psoriasis that was not controlled with trial of topical and systemic treatments. In conclusion, the U.S. Food and Drug Administration (FDA) have approved Humira for the treatment of moderate to severe chronic plaque psoriasis. The approval was based on results of two trials that showed marked improvement in skin condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:enrollee has requested authorization and coverage for transoral incisionless fundoplication.Findings:  Three physician reviewers found that the efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials, although the conclusions are contradictory. A randomized trial included 60 patients and found no improvement in esophageal acid exposure compared with baseline at 12 months. Normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of proton pump inhibitors in 61%. The study concluded that no long-term objective reflux control was achieved. At this time, the current medical evidence does not support transoral incisionless fundoplication as an alternative to medical therapy or traditional surgical therapy. Further safety and efficacy comparison is needed with conventional treatment, such as Nissen fundoplication. Guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) report that the long-term follow-up data for transoral incisionless fundoplication is limited. In sum, transoral incisionless fundoplication is not likely to be more efficacious than other treatment options. Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injections for the right knee every six months.Findings:  Two of the three physician reviewers found that the current medical evidence supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to perform another series. The peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. In this case, the patient has been diagnosed with osteoarthritis of the right knee with supportive clinical examination findings. He has been treated with Synvisc One injections to the right knee every six months for the past year. He has reportedly achieved pain reduction and ability to reduce his anti-inflammatory medication use with the injections. There is support for one Synvisc One injection for the treatment of his right knee osteoarthritis. Thus, one Synvisc One injection for the right knee is likely to be more efficacious than other treatment options. At this time, there is a lack of support for ongoing injections every six months, as the need for continued services should be established based on the ongoing response to these injections. Final Result: The reviewers determined that a portion of the requested services 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 partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a brachial plexus block for a rotator cuff injury. Regional anesthesia of the upper extremity has several clinical applications and is reported to have several advantages over general anesthesia for orthopedic surgery. These advantages, such as improved postoperative pain, decreased postoperative opioid administration, and reduced recovery time, have led to widespread acceptance of a variety of regional nerve blocks. Interscalene block is the most commonly used block for shoulder surgery. Other brachial plexus nerve blocks used for orthopedic surgery of the upper extremity are supraclavicular, infraclavicular, and axillary. Interscalene block for shoulder surgery is at least as effective as general anesthesia alone or other regional anesthetic techniques for decreasing postoperative pain, the need for supplemental analgesics, episodes of nausea and vomiting, and the associated complication rate is low. Interscalene nerve blocks have been shown to be an effective option for regional anesthesia in shoulder surgery. Moreover, interscalene block use is considered a safe and effective anesthetic option. One study concluded that interscalene blocks can provide effective anesthesia for arthroscopic shoulder surgery with minimal complications. Overall, there is high quality evidence to support the effectiveness and safety of interscalene blocks. Given this support, the brachial plexus block for a rotator cuff injury was likely to be more beneficial for the treatment of the patients medical condition that any available standard therapy.Findings:  Three physician reviewers found the brachial plexus block for a rotator cuff injury.Final Result: The reviewers determined that the brachial plexus block for a rotator cuff injury.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that the enrollee had a diagnosis of hepatitis C for an unknown time period. An ultrasound of the liver revealed F1 fibrosis and cholelithiasis. An HCV/RNA viral load was 1.3 million. She has genotype 1a infection. The patient's need for hepatitis C treatment is minimal due to her fibrosis testing result of F1. As per the HCV guidelines from AASLD/IDSA, the patient should be treated at this time. The Harvoni regimen requested is appropriate.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 subspecialty certification in infectious disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Omnitrope growth hormone therapy. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature. At issue in this case is whether the requested Omnitrope growth hormone is medically necessary for treatment of the patients medical condition. Pediatric Endocrine Society guidelines for the definition of idiopathic short stature have not been met. The patients height is 1.7 standard deviations below the mean for age and gender. The guideline definition is below 2.2 standard deviations below the mean for age and gender. There is no prediction of adult height based on bone ages that are younger than 6 years of age. It is unclear which method was used to calculate estimated adult predicted height of five feet five inches. The growth velocity of 7cm/year is an excellent growth velocity and completely normal, which makes the diagnosis of pathologic etiology of short stature unlikely. Therefore, the requested Omnitrope growth hormone is not medically necessary.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 pediatrics with subspecialty certification in pediatric endocrinology 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 review of the record indicates that the enrollee had a history previous spontaneous abortions and one live birth. The provider noted the enrollee was positive for the methylenetrahydrofolate reductase (MTHFR) mutation. The enrollees provider has recommended Nestabs 32mg for the enrollee.According to The American College of Obstetricians and Gynecologists (ACOG), `Homozygosity for the MTHFR gene mutation is the most common cause of hyperhomocysteinemia` which has been associated with a mild propensity to develop thromboses. Homozygosity for the MTHFR C677T polymorphism, as this patient has, is present in 1016% of all Europeans. However, MTHFR mutations by themselves do not appear to convey an increased risk of venous thromboembolism (VTE) in either non-pregnant or pregnant women and there are inconsistent associations between any inherited thrombophilias and recurrent pregnancy loss or stillbirth. Several studies have shown an association between MTHFR C677T homozygosity and recurrent pregnancy loss. The recommended treatment for MTHFR mutations in pregnancy is folate supplementation, usually at a dose of 0.8 to 1 mg per day though some studies have looked at doses up to 5 mg daily. Virtually all prescription prenatal vitamins contain 0.8-1.0 mg folate. The formulary options for this patient and Nestabs contain the same amount of folate equivalent even though Nestabs uses a methyltetrahydrofolate formulation. There is no data that this formulation improves outcomes in the setting of MTHFR mutations. Any prenatal vitamin would be adequate for decreasing the risk of miscarriage and deep vein thrombosis (DVT) in 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 obstetrics and gynecology, with subspecialty certification in maternal- fetal 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Grafix PL placental allografts performed on four dates of service, as well as prospective authorization and coverage for 6 units of Grafix Prime and Grafix PL Prime. Findings: Two of the three physician reviewers found that the services at issue and requested services were not and are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While placental allografts do show promise for the treatment of diabetic foot ulcerations, most if not all of the studies on this type of allograft application are small. The studies advise that more research must be performed in order to demonstrate significant effectiveness of this type of allograft application beyond standard of care. Standard of care includes soft tissue and nonviable tissue debridement, scrupulous cleansing of the wound, antibiotics if necessary (topical and/or oral), and non-weight bearing and/or offloading of the ulcer site. Vascular status must also be assessed in order to demonstrate adequate blood flow for healing. In this case, the Grafix PL placental allograft has been utilized as a supplement to wound debridement and offloading of the ulcer site with the CROW boot. Under these circumstances, the applications of the Grafix PL allograft were not more beneficial than standard of care. In addition, the prospective use of 6 units of Grafix Prime and Grafix PL Prime is not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services at issue and requested services were not and are not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:All three reviewers are board certified in podiatry and are actively practicing. All three 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 reimbursement for residential treatment center services. The Health Plan has denied this request indicating that the services at issue are not medically necessary for treatment of the enrollees substance abuse. At issue in this case is whether the requested residential treatment center level of services provided were medically necessary for treatment of the patients behavioral health condition. The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care higher than outpatient is indicated for patients who: do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use. Lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting. The patient requires safe and stable living environments in order to develop their recovery skills thus qualifying for treatment. Rehabilitation is the essential component that should follow detoxification to help the patient maintain sobriety and reduce risk of relapse. Given the severity of the patients illness and his continuing to have symptoms of restlessness/cravings through his stay residential; treatment was in accordance with generally accepted standards of medical practice and clinically appropriate for the patient's illness and therefore medically necessary.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Guardant360 comprehensive liquid biopsy. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered within the current standard of care. Numerous gene alterations have been identified that impact therapy selection. Further, the National Comprehensive Cancer Network (NCCN) guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. For these reasons, the Guardant360 comprehensive liquid biopsy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Guardant360 comprehensive liquid biopsy was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for platelet rich plasma therapy. Findings: Two of the three physician reviewers found that platelet rich plasma therapy was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. While platelet rich plasma (PRP) injections have been popular among professional athletes, the science behind PRP injections remains unconvincing. There is limited reliable clinical evidence to guide the use of PRP injections. Although no major long-term or permanent complications have been reported in these relatively short-term clinical trials, it remains to be seen what the results will be with more widespread application of PRP injections. Long-term benefits of PRP have not been demonstrated yet for the treatment of osteoarthritis. In this case, the patient is being treated for symptomatic right hip osteoarthritis secondary to femoroacetabular impingement. At this time, there is no high quality evidence to support the efficacy of PRP for the treatment of the patients diagnosed condition. There is a lack of evidence to permit conclusions on net health outcomes for the use of PRP under these circumstances without the presence of well-designed and executed randomized controlled trials with adequate follow-up regarding outcomes and potential complications. Thus, the platelet rich plasma therapy provided to the patient was not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery and are actively practicing. All three 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.