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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Verzenio, Herceptin, and Faslodex. The records provided for review document that this patients diagnoses include secondary malignant neoplasm of liver and intrahepatic bile duct, malignant neoplasm of central portion of right female breast, and malignant neoplasm of breast, unspecified site. The patients provider has recommended treatment with a regimen consisting of Verzenio, Herceptin, and Faslodex. The recently published results of the monarcHER trials showed a significant progression free survival in patients that were ER positive and HER2 positive treated with abemaciclib plus Herceptin with Faslodex versus Herceptin plus standard of care chemotherapy. This option does not use chemotherapy and is likely to be better tolerated then HER2-based chemotherapy, especially with the increased risk of infection. Given these findings, the requested Verzenio, Herceptin, and Faslodex are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested Verzenio, Herceptin, and Faslodex are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication regimen 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 overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in medical oncology with subspecialty certification in hematology and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certifications in medical oncology and hematology and is 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 Xolair injections every 4 weeks.Findings: The submitted documentation supports that the requested medication is medically necessary. Xolair is FDA-approved and supported in the asthma treatment guidelines for the management of persisting asthma (despite combined ICS/LABA therapy) in patients with allergic phenotypes based on elevated IgE levels above 30 IU/mL. In this case, the patient has severe, persistent allergic-type asthma despite combined high-potency inhaled corticosteroid and long-acting beta agonist therapy. The patient also has serum IgE levels above 30 IU/mL that suggest an allergic phenotype of asthma. Furthermore, the patient has already demonstrated an excellent response to Xolair with improved asthma control. Under these circumstances, the requested Xolair injections every 4 weeks are medically necessary for the patients medical condition.Final Result: The reviewer determined that the requested medication is medically necessary for 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 pulmonary disease, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Gammagard infusions 60 grams every four weeks. This patients records document small fiber neuropathy, which the provider noted is likely due to Sjogrens. The provider has recommended treatment with Gammagard infusions. There is a lack of prospective randomized controlled clinical studies demonstrating the long-term safety and efficacy of intravenous immunoglobulin (IVIG) for the treatment of patients with small fiber neuropathy. Gaillet and colleagues reported data suggesting that IVIG treatment can be effective and well-tolerated in patients with small fiber neuropathy. However, the authors concluded that their findings have to be confirmed in a randomized double-blinded placebo-controlled trial. IVIG has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic inflammatory demyelinating polyneuropathy based on large controlled studies confirming the short- and long-term safety and efficacy. There is an absence of adequate data showing positive health outcomes and minimal adverse effects with IVIG for small fiber neuropathy. Standard therapies such as gabapentin and tricyclic antidepressants have been shown to reduce pain associated with polyneuropathy with minimal side effects. This patients records do not document that the patient has exhausted the standard of care medications for treatment of small fiber neuropathy. For these reasons, the requested Gammagard infusions 60 grams every four weeks are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the requested Gammagard infusions 60 grams every four weeks are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in neurology with subspecialty certification in vascular neurology and is actively practicing. Physician reviewer 2 is board certified in neurology with subspecialty certification in neuromuscular medicine and is actively practicing. Physician reviewer 3 is board certified in neurology and is 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 patient has requested authorization and coverage for Xeljanz XR 11 mg tablets. Findings:  The physician reviewer found that treatment guidelines for rheumatoid arthritis state that when at patients disease activity is moderate to severe, despite the use of disease modifying anti-rheumatic drug (DMARD) therapy, then a tumor necrosis factor (TNF) inhibitor or non-TNF biologic could be added. The records provided for review document that this patient has a diagnosis of rheumatoid arthritis. Treatment has included hydroxychloroquine, methotrexate and prednisone. The patients provider has recommended treatment with Xeljanz XR 11 mg tablets. Additional documentation submitted by the patients provider reported that the length of the patients treatment with methotrexate was more than three months. On the basis of the current documentation, treatment with Xeljanz XR 11 mg tablets is appropriate for this patient. Therefore, the requested Xeljanz XR 11 mg tablets are medically necessary for 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 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: The patient has requested authorization and coverage for referral to a neurosurgeon. This patients computed tomography (CT) scan of the head report did not demonstrate a brain bleed and magnetic resonance imaging (MRI) did not reveal any foraminal or central canal stenosis. However, the CT scan of the head did show a mega cisterna magna versus arachnoid cyst midline posterior fossa. An arachnoid cyst is an abnormal mass in the brain that can be symptomatic causing brainstem and cerebellar compression with symptoms such as gait disturbance and headaches. When arachnoid cysts are identified and reported to be symptomatic, the special knowledge and training of a neurosurgeon is needed to properly scrutinize the patients imaging studies, evaluate the history and perform a physical examination, in order to determine if the findings on the CT scan demonstrate a symptomatic lesion. For these reasons, the requested referral to a neurosurgeon is medically necessary for this patient. 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 overturned. Credentials/Qualifications: The reviewer is board certified in neurosurgery 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: The patient has requested authorization and coverage for claviculectomy, acromioplasty, and rotator cuff repair. In this case, the patient presents with left shoulder subacromial impingement, acromioclavicular arthrosis, and biceps tenodesis. Progress notes documented extreme pain, which is affecting her overall health due to her lack of sleep. Focused physical examination of the left shoulder revealed full active range of motion and pain with overhead reaching. The patient also has positive Hawkins, Neers, and OBriens signs. There is good strength with rotator cuff testing. Tenderness to palpation is noted at the biceps groove. History and physical examination, with MRI findings support a significant persistent impingement syndrome, partial and even possible full thickness cuff tear affecting activities of daily living. There is pain noted with overhead reaching and nocturnally. The provider documented that the patient has failed a reasonable trial of conservative treatment modalities including activity modification, medications. For these reasons, the requested claviculectomy, acromioplasty, and rotator cuff repair are medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for consultation and treatment with a regenerative medicine specialist. Findings:  The physician reviewer found that records document treatment with fluoroquinolone therapy in the past with current complaints of headaches, brain fog, generalized body aches, sleep disturbance, and irritable bowel symptoms. The patient expressed concern for the possibility of fluoroquinolone toxicity. Fluoroquinolones have been associated with reported increased risks for development of tendinopathy and peripheral neuropathy. Some data suggests that the risk of fluoroquinolone-associated tendon pathology is higher in certain populations such as patients older than 60 years of age, those on concomitant corticosteroids, solid organ transplant recipients, and patients with renal insufficiency. Treatment includes discontinuation of fluoroquinolone therapy and care for the resultant musculoskeletal issues. One case report described improved symptomatology following intravenous antioxidants, amino acids, an elimination diet, and probiotics for suspected fluoroquinolone toxicity. However, the authors acknowledged that on review of their findings, it was ultimately unknown whether the patients symptoms were caused by the fluoroquinolone medication. Based on this patients records, there is no indication for consultation with a regenerative medicine specialist for this suspected condition. There is no expectation of clinical benefit with any therapy beyond usual care for arthralgias or other musculoskeletal symptomatology that can be directed by a non-regenerative medicine specialist. Moreover, there is a lack of medical literature or clinical trials demonstrating the clinical benefits intravenous antioxidant therapy and amino acid therapy over placebo for this patients condition. For these reasons, the requested consultation and treatment with a regenerative medicine specialist is not medically necessary for evaluation and 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 physical medicine and rehabilitation 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: The patient has requested reimbursement for an echocardiogram performed at the Mayo Clinic Hospital in Rochester, MN. In this case, while the patient appeared at low risk for ischemic or arrhythmic cardiac disease due to her young age and a lack of significant risk factors or family history, she had a history of recurrent and severe chest discomforts resulting in admission to the emergency department and an episode associated with reported syncope. The provider recommended stress echocardiography to evaluate the patient for structural or valvular heart disease, exercise-induced ischemia, or ectopy as an etiology of her symptoms. Given the patients persistent and recurrent symptoms, a definitive non-invasive cardiac evaluation for exercise-induced ischemia, both microvascular and large vessel, exercise-induced arrhythmia, or structural heart disease was medically indicated. Therefore, the echocardiogram performed at the Mayo Clinic Hospital in Rochester, MN was medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the service at issue was medically necessary for evaluation 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for fetal echocardiography with doppler color flow velocity mapping services. Findings:  The physician reviewer found that  guidelines and medical literature supports evaluation with an anatomic scan including standard cardiac anatomy in the latter part of the first trimester for all pregnancies. Data suggest that a subsequent separate fetal echocardiography is recommended when there is an increased risk of cardiac anomalies. As noted by Copel and colleagues, The optimum gestational age for screening for structural fetal cardiac anomalies is 18 to 22 weeks of gestation. Fetal cardiac anatomy can be visualized well at this stage of pregnancy, a complete fetal anatomic survey can be performed, and there is time for further evaluation. Per the authors, A standard obstetric ultrasound examination includes assessment of the four chambers and ventricular outflow tracts of the fetal heart. The inclusion of views of the outflow tracts increases the likelihood of identifying conotruncal anomalies. The authors concluded that this work-up is consistent with the recommendations for sonographic screening of the fetal heart from the American College of Obstetricians and Gynecologists (ACOG) and Society for Maternal-Fetal Medicine (SMFM). In this case, the patient underwent evaluation with a standard ultrasound. Subsequently, her provider recommended a fetal cardiac echocardiography given the elevated risk of fetal cardiac anomalies. Indications with a high-risk profile include maternal pregestational diabetes mellitus or diabetes mellitus diagnosed in the first trimester and pregnancy conceived by assisted reproduction technology. This patient became pregnant through use of assisted reproduction technology. Given these findings, the ultrasound with fetal echocardiography with doppler color flow velocity mapping services were medically necessary for evaluation of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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: The patient has requested authorization and coverage for a Synvisc-One injection in both knees. Per the medical literature, although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, the patient tried and failed other conservative treatments, with the alternative being a total knee arthroplasty. Given the patients limited options and based on the current medical literature, the requested services are medically indicated. Therefore,  Synvisc-One injection in both knees is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for proton beam radiation therapy. There is insufficient data to suggest treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. In a multi-institutional analysis of 1850 patients with low or intermediate risk prostate cancer, Vapiwala and colleagues found no significant difference in gastrointestinal or genitourinary toxicities between patients receiving hypofractionated intensity-modulated radiation therapy (IMRT) and those receiving proton beam therapy. The authors further found no difference in disease control between the two modalities. The American Society for Radiation Oncology (ASTRO) states, Proton beam therapy for primary treatment of prostate cancer should only be performed within the context of a prospective clinical trial or registry. The National Comprehensive Cancer Network (NCCN) guidelines for the treatment of prostate cancer do not note a clear demonstrated benefit of proton therapy over standard treatment. Given that conventional radiation therapy techniques are associated with a high level of safety and efficacy, the requested services are not medically indicated. Therefore, proton beam radiation therapy 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 radiation 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.