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 Invokana for treatment of her type 2 diabetes.  Findings:  The physician reviewer found that Sodium-glucose co-transporter-2 (SGLT-2) inhibitors belong to the American Diabetes Association algorithm in the treatment of patients with uncontrolled diabetes mellitus type 2. Jardiance has an additional U.S. Food and Drug Administration (FDA) approved indication that places it in advantage over Invokana. Jardiance reduces the risk of cardiovascular mortality in adults with type 2 diabetes and cardiovascular disease based on the EMPA-REG OUTCOME study. This study showed that over a median follow-up of 3.1 years, treatment with Jardiance reduced the composite outcome of myocardial infarction, stroke, and cardiovascular death by 14% and cardiovascular death by 38%. Whether other SGLT-2 inhibitors will have the same effect in high-risk patients or other SGLT-2 inhibitors will have a similar effect in lower-risk patients with diabetes remains unknown. Therefore, Invokana is not medically necessary as the Health Plans formulary SGLT-2 inhibitor Jardiance has the additional advantage of decreasing cardiovascular mortality. 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: Physician 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: An enrollee has requested authorization and coverage for a total hysterectomy. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the requested procedure in this clinical setting. The medical record does not contain enough supporting data for long standing pelvic pain that would make a recommendation for a medically necessary hysterectomy. The consensus guidelines that are referenced indicate that a thorough work up should be undertaken in a patient with chronic pelvic pain.  This work up includes imaging studies and laboratory studies. The guidelines state that minimally invasive therapies should be used before considering a total hysterectomy.  With this in mind, the guidelines state that there is little evidence that hysterectomy will cure chronic pain.  Hysterectomy may be considered for endometriosis when there is documented failure of other treatments. As such, the records provided do not support the need for a total hysterectomy. In this patients case, the documentation shows that the patient has used oral contraceptive pills for brief a period of time.  The record states that the patient had a laparoscopy. However, there is no operative report to document the findings such as endometriosis or adhesive disease. There are no imaging studies to support the need for hysterectomy. There is no documentation in the medical record of a discussion with the patient of the risks and benefits of hysterectomy. For these reasons, a total hysterectomy is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the his dyslipidemia. Findings:  Three physician reviewers found that based on the records provided, this patient presents with a diagnosis of dyslipidemia. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phosholipase A2 (Lp-PLA2), sub-classifications of LDL, high density lipoprotein (HDL) cholesterol subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment changes or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Final Result: 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: Reviewer 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma Gene Expression Classifier (GEC) for evaluation of her thyroid nodule. Findings:  Three physician reviewers found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma thyroid FNA analysis utilizes a GEC in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. 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. Credentials/Qualifications: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Enbrel 50 mg twice weekly treatment of his psoriasis.  Findings:  The physician reviewer found that this patient presents with plaque psoriasis. He has shown good clinical response to Enbrel 50 mg twice weekly, but loses efficacy when dosed at the U.S. Food and Drug Administration (FDA) approved maintenance dose of 50 mg SQ weekly. However, the requested increased dosage of Enbrel exceeds the FDA recommended dosage for maintenance therapy. All told, the request for increased dosing is not medically necessary as there are alternative therapies available that would like show better efficacy at typical FDA approved dosages. 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a hospital stay for treatment of her chest pain. Findings:  The physician reviewer found that based on the records provided, inpatient admission was not medically necessary for this patient. Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting. Inpatient setting is required when the patient requires diagnostic studies in an inpatient setting, or if it is medically necessary for the patient to remain in the acute inpatient setting. Outpatient observation admission is appropriate when the provider is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the provider anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition with improved symptoms and could have been treated at an observational level of care.  The records note that this this patient was treated with intravenous fluids, Zofran and pain medications in the emergency department. After she was administered treatment, her symptoms improved. At that point, the patient did not require 24 hour inpatient stay. 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for corneal collagen cross-linking for treatment of his keratoconus. Findings:  Three physician reviewers found that the medical evidence supports the requested services in this clinical setting.  Based on the patients vision loss and documented progression, corneal collagen cross-linking is likely to be the most effective treatment available. There is medical evidence which shows corneal collagen cross-linking is a safe and effective procedure for stabilizing corneal ectasia and potentially delaying or preventing the need for full-thickness corneal transplant.  Furthermore, corneal collagen cross-linking for corneal ectasias fulfills an unmet need. There is no other treatment option available to slow or halt disease progression.  Final Result: The reviewers determined that the requested services are 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 ophthalmology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that in most clinical settings, the least restrictive level of care is preferred. In this patients case, continuation of relapse prevention education and treatment did not require the structure of the residential setting. The submitted documentation demonstrates the patient showed mild post-acute withdrawals.  She had a Clinical Institute Withdrawal Assessment (CIWA) score of 7, and showed mild tremor, sweats, anxiety, and headache.  The records noted that she was highly motivated, and availed herself of all groups, individual, and family treatments. She was noted as compliant.  Her mood was depressed and anxious. Her affect was for the most part flat, with occasional lability.  She planned to go to sober living, as she was aware that her husband triggered her.  The documentation noted that she was alert and oriented in all spheres. She was not a danger to herself or others, and she was medically and psychiatrically stable.  In addition, there were no emotional, behavioral, cognitive, impulsive, or manic factors, which would preclude recovery at a lower level of care.  Further, she was highly motivated and engaged in treatment.  Moreover, she had no recent substance abuse treatment, and there was no evidence that she would have relapsed if treatment were rendered at a lower level of care.  She was working on issues of anxiety, self-esteem/self-worth, and perfectionism in individual therapy.  The records demonstrate that this patient could have received treatment at a lower level of care. 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 with sub-specialty certification in addiction 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for a 12-weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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. A delay in treatment may result in decreased survival. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate quick dissolve 30 mg #150 per month for treatment of her Crohns disease. Findings:  The physician reviewer found that chronic pain and chronic diarrhea can be considered palliative in nature. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, multiple minimal requirements for opioid prescribing have not been reported. In addition, no objective treatment goals for pain and function are noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might place patients at greater risk for overdose. The CDC also states that 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 to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage of 90 or greater MME per day. In this case, the patient is taking at least 165 MME per day. No medical evidence based rationale is given for this high of a MME per day by the provider when there are alternative available for morphine that work on the same receptors. Loperamide, a synthetic opiate agonist, decreases peristaltic activity and inhibits secretion, resulting in the reduction of fluid and electrolyte loss and an increase in stool consistency.` Also, there are a number of different medications used for chronic diarrhea. Moreover, behavior therapy has not been documented despite much research to support its use for pain. Finally, not all non-opioid medications classes have been optimized or tried for pain or diarrhea. 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 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 lipedema liposuction for treatment of the her lipedema. The physician reviewer found that this enrollee has a diagnosis of lipedema, which is an abnormal enlargement of the extremities. This should be considered a developmental abnormality, as this appears to have begun at an early age. However, the requested surgery is not likely to improve function, as this appears to have already failed to provide improvement with her surgery in 2015. Further, the submitted medical documentation and photographs do not clearly document the surgery will create a normal appearance to the extent possible or provide more than a minimal improvement in the patients appearance. 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 plastic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 testing performed.  Findings:  The physician reviewer found that : Multiplexed genotype testing allows an entire panel of genotypes of interest to be queried at a single time from a single tissue sample instead of doing the tests sequentially. This is the most tissue-efficient approach, particularly when dealing with small tumor samples. In addition, multiplexed genotyping is the most time-efficient process for screening patients, thus facilitating prompt treatment or protocol inclusion. The National Comprehensive Cancer Network guidelines endorse broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. For the treatment of patients with advanced non-small cell lung cancer, broad molecular profiling, such as Guardant360 testing, is considered standard of care.  In sum, Guardant360 testing performed  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: 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 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 Epclusa. Findings:  The physician reviewer found that according to 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, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% with this regimen . The guidelines no longer recommend Sovaldi with ribavirin as first-line therapy for genotype 3 hepatitis C. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Epclusa is supported as 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.