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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by researchers, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  In sum, breast tomosynthesis was likely to have been more effective than other methods of evaluation. Final Result: Three 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:   All three reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a transthoracic echocardiogram for evaluation of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based on the records provided, the patient had a normal echocardiogram and no documentation subsequent to that to indicate any new cardiac symptoms, abnormal cardiac physical examination findings or electrocardiographic changes.  In this circumstance, the documentation provided does not demonstrate the need for a repeat echocardiogram at this time.  There is a lack of support for the requested services in this clinical setting.  All told, the requested transthoracic echocardiogram is not medically indicated 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 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 residential treatment program services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based on the physical and clinical assessments, a reasonable treatment plan was developed.  There was no subsequent documentation indicative of a change in status that would necessitate more intensive services.  Further, the medical records from the residential facility lacked critical documents useful in the level of care determination process.  Additionally, the patient had a safe residence and was motivated for care.  Despite the contemporaneous diagnoses of depression anxiety, the patient had no safety concerns.  She had not engaged in chemical dependency aftercare following previous residential admission.  There was no evidence to suggest that a less restrictive treatment setting would have been insufficient at the time.  Thus, residential treatment program services were not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested temazepam, Ambien, Klonopin, fentanyl, Norco, and Adderall for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  Short release/acting opioids, such as Norco, are associated with a high risk of dependence and tolerance.  Researchers reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Researcehrs also reported that prolonged use of high-dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity.  All told, the requested temazepam, Ambien, Klonopin, fentanyl, Norco, and Adderall are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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:  An enrollee has requested Otezla for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been treated with medications, with reported side effects to these medications. The available medical records do not document or provide objective evidence of ongoing disease activity or progression of disease activity that would necessitate treatment with an escalation of therapy with Otezla.  On the basis of the available medical records and per the peer-reviewed medical literature, Otezla 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 internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xiaflex for treatment of his medical condition. Findings:  The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa.  This plaque is not visible, and depending on the severity of the condition, this condition can cause penile curvature with erection.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The current medical evidence supports Xiaflex in this clinical setting.  All told, Xiaflex is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. The fixed-dose combination ledipasvir-sofosbuvir (Harvoni) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. The treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. According to the literature, treatment duration of 8 weeks can be considered in treatment-naive patients, without cirrhosis, who have a baseline HCV RNA level less than 6 million IU/mL based on post-hoc analysis of the clinical data from the ION-3 trial. Therefore, the patient should be approved for Harvoni to prevent further development and progression of fibrosis due to ongoing HCV infection and to avoid potential complications of advanced liver disease. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Praluent for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  This patient presents with coronary risk and markedly elevated cholesterol despite maximal tolerated statin medication and ezetimibe.  In this circumstance, additional cholesterol lowering is medically necessary to help reduced the risk of developing obstructive coronary disease.  Praluent, a PCSK9 inhibitor, is approved as an adjunct to diet and maximally tolerated statin therapy for the treatment of adults with heterozygous familial hypercholesterolemia or clinical atherosclerotic cardiovascular disease, who require additional lowering of LDL-C. This patient likely has heterozygous familial hyperlipidemia.  PCSK9 inhibitors have been show to reduced adverse cardiovascular outcomes in this setting and are associated with an acceptable safety profile.  All told, Praluent is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The high-risk criteria for this test include a maternal age greater than or equal to 35 years of age, history of previous pregnancy with fetal trisomy, presence of sonographic findings associated with fetal aneuploidy, parental balanced robertsonian translocation with increased risk of trisomy 21 or 13, and screen-positive result for aneuploidy on screening tests.  In this case, the patient had none of these risk factors.  Therefore, gene was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 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:   All three reviewers are board certified in obstetrics and gynecology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per the medical evidence, there is increasing evidence of value of tomosynthesis in breast imaging related to the tomographic technique and the associated ability of radiologists to differentiate glandular tissue from underlying architectural distortion or mass.  There is ample data showing decreased callbacks and increased detection of small cancers when tomosynthesis has been added to the usual two-dimensional mammographic images.  Thus, the addition of breast tomosynthesis to the two-dimensional mammogram films was likely of more benefit to the patient than if two-dimensional mammography alone had been done. Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested infusions of intravenous immune globulin (IVIG) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is a term used for children that have abrupt onset of tics and/or obsessive compulsive disorder symptoms following group A beta hemolytic streptococcal (GABHS) infection. Operational criteria include the following: presence of obsessive compulsive disorder and/or tic disorder meeting standardized criteria, onset between three years and the onset of puberty, episodic course of symptom severity with abrupt onset of symptoms or significant symptom exacerbations, association with streptococcal infection with positive throat culture or rising anti-streptococcal antibody titers, and association with neurological abnormalities on examination. Despite these criteria and others, there is ongoing debate regarding the diagnosis of PANDAS, including uncertainties with clinical definition and pathophysiology.  There is ongoing debate about the presence of antineuronal antibodies and the means of their formation (molecular mimicry, bystander activation, epitope spreading).  In a recent review of the topic by Tan and colleagues, the following treatment recommendations were made: antibiotics are indicated for treatment of GABHS infection, but the utility of prophylaxis has not been consistently demonstrated, and the use of immunomodulatory therapies (including IVIG) will need further research before it can be recommended. These authors concluded the following: without more knowledge about PANDAS, and definitive evidence linking GABHS infections to neuropsychiatric symptom exacerbations by way of immune-mediated processes, the diagnosis of PANDAS and the use of long-term antibiotic prophylaxis or any immunomodulatory therapies in place of or concomitantly with conventional therapies cannot be recommended. Based on this information, infusions of IVIG are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue 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 pediatric critical care 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 Sovaldi and ribavirin for 24 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend that all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions.  This patient has failed therapy with interferon.  Per the guidelines, treatment-experienced genotype 3 patients should be treated with daily Sovaldi and ribavirin and weekly peg-interferon for 12 weeks.  Interferon-ineligible patients should be treated with Sovaldi and Daklinza for 24 weeks.  Because peg-interferon will not be used, and because the request is for 24 weeks of therapy rather than 12 weeks, the requested treatment regimen is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Anser IFX testing for evaluation of her medical condition.  Findings: Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. Prometheus Anser IFX Test is a quantitative measurement of serum infliximab and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab (ATI) may play a role in primary or secondary response failures. However, there is a lack of well controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. Moreover, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Final Result: Two reviewers determined that the testing at issue 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:   All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.