Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for chiropractic treatment for treatment of levoscoliosis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records indicate that this patient has received chiropractic care as maintenance therapy. Despite the patients report that he has new injuries, there is no documentation of any new injuries in his chiropractic notes. When further clinical improvement cannot reasonably be expected from continuous ongoing care, the chiropractic treatment becomes supportive rather than corrective in nature, and the treatment is considered maintenance therapy. All told, the requested chiropractic treatment is 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 chiropractic care 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 the FoundationOne gene testing. Findings:  The physician reviewer found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines indicate that the efficacy of standard of care treatment for recurrent glioblastoma is suboptimal, and for eligible patients consideration of clinical trials is highly encouraged. Prior treatment may impact enrollment in the majority of clinical trial options. Molecular characterization of primary brain tumors/gliomas has had a substantial impact on stratification and eligibility in clinical trials for central nervous system neoplasms over the last 10 years, and is increasingly becoming a common part of standard neuro-oncology management. Molecular profiling can identify potential molecular markers for which ongoing clinical trials may be available. Thus, the use of molecular profiling with FoundationOne testing was likely to be more beneficial for evaluation than available standard therapy to guide decision making.  Final Result: Two of the three 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.Credentials/Qualifications: Physician reviewers 1, 2 & 3 are  board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are an 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 Epclusa for 12 weeks. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial .  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Epclusa for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Guardant 360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. Patients with adenocarcinoma of the lung found to have certain epidermal growth factor receptor (EGFR) mutations are appropriately treated with erlotinib. Upon progression, it is important to reassess their mutation status, to see if the cells now have a T790M mutation, for which there is a specific and approved treatment, Tagrisso. This latter testing can be done by plasma testing via Guardant 360 test. In this patients case, Guardant 360 test was likely to have been of greater benefit than 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: The parent of an enrollee has requested authorization and coverage for a whole house generator.  Findings:  The physician reviewer found that the physician reviewer found the patient is technology dependent for survival. He requires mechanical ventilation, supplemental oxygen, suction, and continuous feedings via pump. Without these interventions, he would not be able to be cared for in the home. With power interruption, his technology is available only as long as battery power provides functionality. In the case of prolonged outage, as may occur with poor weather conditions, downed power lines, or prolonged repair/expansion, he must be taken to the emergency department for management. This is not a viable option for this family with a single caregiver. The current standard is to facilitate disaster and emergency preparedness amongst families of technology dependent children to prevent unnecessary morbidity and increased potential for mortality. A whole house generator system properly designed and operated is thus medically indicated. All told, the requested whole house generator is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging of the spine (MRI). Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting. Over the years, the American College of Radiology (ACR) has established appropriateness guidelines, directing appropriate evaluation of various common conditions. In  1998, an Appropriateness Criteria was established for chronic neck pain. This guideline criteria was subsequently reviewed in 2013. There are clear variations as to the clinical presentation of chronic neck pain. This patients presentation fits within one of the criteria guideline parameters. The variant that best describes this patient is either Chronic neck pain, radiographs normal. Neurologic signs or symptoms present, or Radiographs show degenerative changes. Neurologic signs or symptoms present.  For each of these presentation, the ACR recommends an MRI of the cervical spine as the most appropriate study to perform. The ACR states: The utility of MRI in the evaluation of patients with chronic neck pain and degenerative cervical disorders is now well established.  Given its lack of ionizing radiation, excellent depiction of bone marrow signal, intervertebral discs, facet arthropathy and spinal stenosis, MRI has supplanted [computed tomography] CT as the first line advanced imaging study in patients with chronic neck pain.  In a clinical setting of acute pain, especially following trauma, one could make the case that conservative treatment is more appropriate.  Often times, many patients will see their symptoms resolve simply by allowing the body to heal.  However, this patient has had symptoms for at least six months, and has a documented radiculopathy. In sum, while surgery or even an injection may not be imminent, it would still be helpful for this patient and the provider to have as much information as possible prior to initiating further therapy. This patients symptoms have been present for six months, and she reported considerable discomfort affecting her activities of daily living.  Even if a simple steroid injection is to be performed, it would be helpful to have some guidance regarding how many levels to inject. Therefore, MRI is medically necessary for the evaluation of this patients medical condition.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturnedCredentials/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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for occipital nerve block treatment (CPT code 64405). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the efficacy of the services at issue in this clinical setting. The records indicate that this patient has chronic migraine, despite a variety of preventives. The patient continues to be treated with rescue therapeutics including opiates, butalbital, and Decadron. Moreover, the diagnoses and examinations are consistent with occipital neuralgia as well as chronic migraine. There is evidence for the treatment of migraine and occipital neuralgia with occipital nerve block. Occipital nerve block is a standard of care for patients with chronic migraine, episodic migraine for rescue, as well as occipital neuralgia. All told, the occipital nerve block treatment (CPT code 64405) was likely to have been more efficacious than the standard options for the treatment this patients medical condition.Final Result: Two of the three reviewers determined that the services 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: Physician reviewers 1,2 & 3 are board certified in neurology 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 expression profiling. Findings:  The physician reviewer found that Uveal melanoma (UM) is the most common primary cancer of the eye and has a strong propensity for metastasis. Clinicopathologic factors are not accurate enough for individualized patient care. DecisionDx UM is a gene expression based molecular classifier used to determine prognosis on a fine needle aspiration of the tumor and guide therapy. This profile test has been validated in 459 patients and was demonstrated to be a better prognostic marker than monosomy three classification or tumor, lymph nodes, and metastasis (TNM) classification. The test allows patients to be stratified into risk categories such that high risk patients can be offered intensive metastatic surveillance and adjuvant therapy while low risk patients can be spared these interventions. This test is now used as part of the standard of care for treatment of ocular cancers. All told, the gene expression profiling was likely to have been of greater benefit than other modalities for the evaluation this patients medical condition. Final Result: Two if the 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 reviewers 1, 2 & 3 are  board certified in internal medicine with sub-specialty certification in medical oncology 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 Epclusa (sofosbuvir-velpatasvir 400-100 mg), 28 tablets for 28 days for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. Findings:  The physician reviewer found that the medical records provided for review did not support the multiple genetic tests performed. The patient was not being treated with any of the medications the genetic testing was performed to assess in terms of efficacy or resistance. In addition the patient was not being treated with anticoagulation, and was not noted to have had deep vein thrombosis (DVT) or evidence of hypercoagulable state. Moreover, the records do not document how the results of the multiple genetic tests performed would be used or how results would impact treatment. Further, the patient has evidence of dyslipidemia and was being treated with standard treatment, in this case atorvastatin. Advanced lipoprotein testing has not been found to be more beneficial than standard lipid profiles and has not been definitively demonstrated to positive impact health outcomes. Based on the clinical documentation provided for review, the laboratory testing provided was not likely to be more beneficial for treatment of the patients medical condition than any standard available therapy.Final Result: All three of The 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: Physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin 10 mg four tablets orally in the morning and three tablets orally in the evening for treatment of the enrollees fibromyalgia and chronic pain syndrome. Findings:  The physician reviewer found that 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 settings. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient wants 105 MME per day and was on recently before 180 MME per day, even though the patient reported to being able to get by with 52.5 MME per day. There is no medical evidence based rationale is given for this high of a MME per day by the provider nor long term consequences with the continual increase. Risk and benefit analysis must be performed to justify the requested level of 105 MME per day. It is unclear what the plan is for any unseen future pain insults the patient would experience while already on 105 MME per day. Additionally, it appears that tolerance has taken place since the start of the narcotics. The medical evidence indicates that dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There are no improved or changed objective function noted with the requested dose escalation to 135 MME per day. There are no clear objective goals established by the provider with this high dose of opioid. Other non-pharmacological methods of managing the pain have not been done or even addressed. The records do not mention behavior therapy despite much research to support its use. Final Result: The reviewer determined that the requested medication dosage 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 anesthesia 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg one tablet daily for 16 weeks. 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 Zepatier with ribavirin for 16 weeks when nonstructural protein NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial.  In this patients case, the specific M28 mutation found is known to result in lower efficacy of Zepatier. Therefore, 16 weeks of Zepatier with ribavirin would be indicated. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, Zepatier 50-100 mg one tablet daily for 16 weeks is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.