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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for subcutaneous testosterone implant treatment for treatment male hypogonadism. Findings:  Two physician reviewers found that the evidence shows that testosterone pellets (Testopel() provide sustained levels of testosterone for at least four months and up to six months in men with testicular hypofunction. Implantation of greater or equal to eight pellets achieved optimal results with respect to peak mean testosterone level and duration of effect. The medical literature supports that testosterone pellets were generally well tolerated. In this patients case, the documentation provided shows that this patient has had a favorable response to subcutaneous testosterone treatment. The patients testosterone levels were increased to 337 ng/dl. This was an improvement to his previous levels. Additionally, this treatment option has been an available therapy for patients with low testosterone levels. As such, subcutaneous testosterone implant treatment received on 6/27/17 was likely to have been more efficacious than any other available treatment modality for treating this patients medical condition. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in urology 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 gene testing for evaluation of melanoma of the left eye. Findings:  Three physician reviewers found that the gene testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Cytogenetic testing of uveal melanoma is an established method of laboratory evaluation of melanomas. The medical literature supports the routine use of this test for patients with uveal melanoma. The standard of care is to adjust a patients monitoring and surveillance based on the genetic profile of the tumor. In addition, the counseling and eligibility for clinical trials is based heavily on the tumor genetic profile. In sum, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing 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. Reviewers 1, 2 and 3 are board certified in ophthalmology 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 authorization and coverage for the Medtronic 670G insulin pump for treatment of the enrollees type 1 diabetes. Findings:  The physician reviewer found that the request for Medtronic 670G insulin pump is medically necessary for treatment of the patients medical condition. The Medtronic 670G system is U.S. Food and Drug Administration (FDA) approved for patients with type 1 diabetes 14 years of age and older. The Medtronic 670G system includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor (CGM) sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. Medical studies show that the closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes. This feature is of importance to this patient given that the patient has documented hypoglycemia unawareness and hypoglycemic seizures. The Medtronic 670G system will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. This system will allow the patient to remain within the recommended target range most of the time. With this system, the patient will be able to keep his hemoglobin A1c (HbA1c) closer to goal and while minimizing hypoglycemic events. The ability of this pump to minimize hypoglycemic reactions by decreasing or stopping insulin delivery before hypoglycemia occurs is the most important feature that makes this system medical necessary for the proper management of this patients diabetes type 1. Final Result: The reviewer determined that the requested device 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Praluent for treatment of the enrollees hypercholesterolemia and severe atherosclerotic cardiovascular disease. Findings:  The physician reviewer found that based on the records provided this patient presents with statin intolerance and increased coronary risk but no documented symptoms of coronary ischemia, ischemia on stress testing, or clinical coronary events. The patient has an elevated calcium score with up to 70% stenosis in the left anterior descending coronary artery. The coronary CT scan as reported does not accurately quantify stenosis likely due to the presence of significant calcium. In summary, the documentation provided does not confirm the presence of obstructive coronary disease. Praluent is a PCSK9 inhibitor that has been demonstrated to be safe and effective for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical obstructive atherosclerotic heart disease who require additional lowering of low density lipoprotein (LDL) cholesterol. This patient does not meet these criteria. PCSK9 inhibitors have not been studied in other patient populations. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this setting. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine and of the neck spine. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for the requested diagnostic procedure. There is a lack of support in the peer-reviewed literature supporting the requested diagnostic procedure in this clinical setting. The medical records submitted for review demonstrate evidence of back pain, however there is a lack of documentation showing the patient has had a trial of intensive anti-inflammatory medications as well as physical therapy and other conservative measures. Given the lack of conservative treatments tried and failed, the request for MRI of the lumbar spine and of the neck spine is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 authorization and coverage for ondansetron 8 mg, one tablet every eight hours, OxyContin 10 mg, one tablet every 12 hours, oxycodone extended release 40 mg, one tablet every eight hours, Wellbutrin XL 150 mg extended release, one tablet two times a day, and nortriptyline 50 mg, one tablet per day for treatment of chronic pain. Findings:  The physician reviewer found that With regards to the medications OxyContin and oxycodone ER, there is a lack of support for the requested medications in this clinical setting. In the documentation available for review, the stepwise World Health Organization (WHO) ladder for pain relief is considered a reasonable approach to pain control in the palliative and the non-palliative setting. The medical literature suggests clinicians to consider alternative options to opioids as well as to wean patients to lower doses of opioids or even off opioids. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention states that when starting opioid therapy, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established in this patients case. Finally, not all non-opioid medications classes have been optimized or tried in this case. Concerning the other medications, the U.S Food and Drug Administration (FDA) states ondansetron is indicated for the treatment of nausea and vomiting, secondary to chemotherapy, radiotherapy, or for postoperative reasons. It is also unclear from the records how ondansetron has affected this patients nausea. In this patients case, the records do not support that ondansetron is being prescribed for one of the FDA indications. The records indicate that while nortriptyline can be administered for the treatment of depression, this medication was recently discontinued by the neurologist in favor of a different medication. As for the medication Wellbutrin, the FDA reports that this medication may be indicated for depression but is contraindicated in patients who abruptly discontinue sedatives. Wellbutrin should not be used when sedative medications, like opioids, are being discontinued. 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 authorization and coverage for Insj biomechanical device and second level discectomy/spinal fusion. Findings:  The physician reviewer found that the request for Insj biomechanical device and second level discectomy/spinal fusion is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient presents with chronic back pain with ill-defined lower extremity symptoms without specific dermatomal or myotomal findings of a lumbar radiculopathy . The records do no demonstrate that the patient has localizing features to the pain. The patient has no symptoms or findings to correlate the L5-S1 level as the pain generator. The patient has symptoms suggestive of SI joint disease, but no detailed SI joint examination. In addition, the patient has not failed conservative management such as physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), home exercise program, cognitive behavioral therapy, or back brace. The patients burning feet are possibly due to peripheral neuropathy, vascular disease, and hip disease, which have not been ruled out. The proposed surgery is not the standard of care in this clinical setting. Therefore, the requested services have 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 neurological 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: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy for treatment of the enrollees fetal alcohol spectrum disorder, attention deficit hyperactivity disorder (ADHD) and behavioral difficulties. Findings:  The physician reviewer found that based on the clinical documentation provided for review, the request for ABA therapy has not been established as medically necessary for treatment of the patients medical condition. There is insufficient support in the peer-reviewed literature for the requested services in this clinical setting. There is some research showing that ABA can be helpful for children with intellectual disability or other behavioral challenges. However, there is a lack of peer-reviewed literature indicating that ABA therapy would benefit the patients diagnoses. 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-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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for panitumumab (Vectibix) 6 mg/kg 390 intravenous every two weeks in combination with dabrafenib (Tafinlar) 150 mg PO two per day plus trametinib (Mekinist) 2 mg PO once a day for treatment of the enrollees colon cancer. Findings:  The physician reviewer found that refractory or relapsed cancer who have exhausted standard treatments are usually considered for clinical trials. Recently, it has become important to identify mutations that may be amenable to targeted therapy. Researchers performed a study of 86 patients where the progression-free survival on a regimen selected by molecular profiling was compared to the progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. Trametinib is an inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF. The MEK kinases are within the same pathway as RAS and BRAF. Thus, it is mechanistically appealing to apply trametinib to tumors with constitutive RAS signaling. Other researchers evaluated dabrafenib combined with trametinib in patients with BRAF mutant metastatic colorectal cancer. The authors noted one complete response and some partial responses with trametinib and dabrafenib in BRAF mutant colon cancer patients. In this patients case, the results from molecular profiling offers a rational selection of the next regimen. Final Result: The reviewer determined that the requested medications 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 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: An enrollee has requested authorization and coverage for hydrocodone 10/325 (quantity 120 pills in 30 days). Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. MRI showed degenerative disc disease in both her neck and low back.  However, clinical practice guidelines do not support the use of chronic opiates for neck and low back pain.  There are a multitude of other therapies available that need to be tried and documented before using chronic opiate therapy.  Further, the use of chronic opiates carries significant risk, and a formal risk/benefit assessment needs to be conducted and documented, in addition to documentation of urine toxicology screens and an opiate maintenance agreement. This is not documented in the records provided. The medical evidence does not support the requested medication quantity in this clinical setting. All told, hydrocodone 10/325 (quantity 120 pills in 30 days) is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication quantity 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: 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 braces for treatment of the enrollees dental condition and are not reconstructive in nature. Findings:  The physician reviewer found that the medical records provided show the patient to have had a congenital cleft of the soft palate which was successfully repaired at a young age.  The records show this repair to have been primarily affecting the soft tissues of the palate and do not demonstrate any issues at that time with the bones of the maxilla.  The submitted documentation included a note from a provider stating the patient needs braces, with no orthodontic records showing the extent of the issues or whether the congenital cleft palate could have been causative to the patients current dental condition. Therefore, while the patient has a history of the congenital abnormality of cleft palate, there is no evidence that the requested dental braces are treatment for or an integral part of the reconstruction of the patients congenital cleft palate. While most orthodontic treatment would be expected to provide some extent of improvement in function and aesthetics, there are no orthodontic records provided which would indicate the requested services will either improve function or create a normal appearance correcting any defects remaining from the patients congenital condition of cleft palate. The submitted records do not show compromise in the patients appearance caused by the cleft of the soft palate. Therefore, the requested services are not shown to provide more than a minimal improvement in the appearance of the patient. In sum, the requested braces are not medically necessary for the treatment of this patient and are not reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of an emergency medical condition. In this case, the patient sustained fractures of the left distal radius and ulnar styloid. The medical records submitted for review do not support that the services provided were emergent given the patients fracture complexity. Therefore, the services provided are not considered emergency medical services. Thus, the patient did not receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive emergency medical services on the dates of service at issue. 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.