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

Nature of Statutory Criteria/Case Summary: The patients parent has requested authorization and coverage for endoscopic thoracic sympathectomy. Findings:  The physician reviewer found that the patient has not tried some standard medical treatments for hyperhidrosis including oral anticholinergic agents or Botox injections, but there is no reasonable expectation that these agents will have any significant or long-lasting benefit for this patient since he has already failed topical Drysol prescription grade aluminum chloride. The oral anticholinergic treatments will dry the entire body, and the patients mouth and eyes will likely dessicate long before any improvement is noted in the hands or axillae. In addition, Botox injections are U.S. Food and Drug Administration (FDA) approved for the axillae, but not the hands. Thoracoscopic sympathectomy is thus considered the treatment of choice for management of this patients massive palmar sweating. The curative effect is immediate and dramatic, immediately impacting the long-term quality of life for the patient. Furthermore, studies have confirmed that it is precisely in teenage years, rather than later in life, that the sympathectomy is most effective with the least compensatory hyperhidrosis side effects, likely because of the plasticity of the immature nervous system. All told, the requested endoscopic thoracic sympathectomy is supported as medically necessary for treatment of this patients massive palmar, axillary and plantar hyperhidrosis. Final Result: The reviewer determined that the requested surgery 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 thoracic 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: The patient has requested reimbursement for the nerve stimulation treatment for treatment of the enrollees overactive bladder, urge incontinence, and interstitial cystitis. Findings:  Three physician reviewers found that patients with refractory overactive bladder (OAB) can have significant detrusor overactivity leading to urinary incontinence. Anticholinergic medications and beta three agonists are considered first-line therapy. Patients who are refractory to medications can be managed by minimally invasive therapies like Botox injection and sacral neuromodulation. Sacral neuromodulation with InterStim is a safe, effective and medically appropriate third-line alternative in patients with refractory overactive bladder looking for long-term therapeutic improvement. The American Urological Association (AUA) guidelines state that, clinicians may offer sacral neuromodulation (SNS) as third-line treatment in a carefully selected patient population characterized by severe refractory OAB symptoms or patients who are not candidates for second-line therapy and are willing to undergo a surgical procedure. This patient has urinary frequency and urgency from overactive bladder that has not responded to behavior modification and pharmacological therapy. Final Result: The reviewers determined that the service at issue was 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 Guardant 360 Test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that there is support for the services at issue in this patients case. The National Comprehensive Cancer Network guidelines for non-small cell lung cancer strongly endorses broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. 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 one by one. 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. In this clinical setting, Guardant 360 Test is considered a standard of care. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Medtronic G670 closed loop insulin pump system.  Findings:  The physician reviewer found that the Medtronic G670 System is approved is approved by the U.S. Food and Drug Administration (FDA) for continuous delivery of basal insulin and administration of insulin boluses for the management of type 1 diabetes. The Medtronic G670 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. Studies show that the Medtronic G670 system increased the percent of in-target [sensor glucose] SG levels and was associated with clinically important reductions in HbA1c values in both cohorts. These findings and the ability of the system to increase the time in-target range, while reducing the time below and above target levels, support its function as a hyperglycemia and hypoglycemia attenuator . Studies also 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 . A peer reviewed study  showed that among adults, the glycated hemoglobin level was lower with the use of a closed-loop system day and night than with a sensor-augmented insulin pump, even when the insulin pump was adjusted appropriately. In this case, the patient has type 1 diabetes that is sub-optimally controlled. The patients HbA1c is above 6.5%. The Medtronic G670 system automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. Thus, this system will allow the patient to remain within the recommended target range and maintain the patients HbA1c while minimizing hypoglycemic and hyperglycemic events. As such, the Medtronic G670 system is likely to be more beneficial for treatment of the patients type 1 diabetes than any available standard therapy.Final Result: All three reviewers determined that the requested device 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 reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for insulin pump (Medtronic 670G)Findings:  The physician reviewer found that at this time, the incremental benefit of automated closed loop control of insulin administration is unclear. The requested device, Medtronic MiniMed 670G system is a fairly new system. While the Medtronic 670G is U.S. Food and Drug Administration approved for management of type 1 diabetes, there is a lack of long term data available demonstrating health outcome benefits of such technology when compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device with or without CGMS.A study published the results of a pivotal safety study of the MiniMed 670G system in the Journal of the American Medical Association. The above studys purpose was limited to the evaluation of the safe use of the 670G auto mode function. This study was not designed to determine the effectiveness of the device compared to conventional methods such as manual daily insulin injections or non-automated insulin pump therapy. The authors concluded that longer term registry data and randomized studies are needed. Therefore, insulin pump (Medtronic 670G) is not likely to be more beneficial than the standard options for the management of this patients type I diabetes. Final Result: Two of the three reviewers determined that the requested device is 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 endocrinology, diabetes and metabolism 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 scar reduction treatment the enrollees possible keloid scar. Findings:  The physician reviewer found that the request for scar reduction treatment is not medically necessary or reconstructive in nature for treatment of the patients medical condition. The patient presented with evidence of a probable hypertrophic scar following resection of a dermatofibroma.  Based on the documentation provided, the Health Plans recommendation for an in-person evaluation is medically reasonable and appropriate for an adequate evaluation of the right forearm. Conservative treatment including scar massage and possible steroid injection should be considered prior to re-resecting the area. Due to the lack of a sufficient evaluation, scar reduction treatment has not been established as medically necessary. In regards as to whether the requested surgery is cosmetic, according to the American Society of Plastic Surgeons (ASPS) Cosmetic surgery is performed to reshape normal structures of the body in order to improve the patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease.  It is generally performed to improve function, but may also be done to approximate a normal appearance. In this case, the patients medical condition constitutes an abnormal structure of the body due to evidence of probable hypertrophic scarring following his right forearm resection. The patients abnormal structure of the body is a result of trauma. However, given the lack of documentation demonstrating a sufficient evaluation of the patients possible keloid scar it would be premature to assess whether the requested surgery is being performed to improve function or create a normal appearance to the extent possible. For the reasons provided, the requested surgery is not medically necessary or reconstructive in nature. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. 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: 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 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 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 for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genitofemoral nerve blocks for treatment of the enrollees groin pain. Findings:  Two physician reviewer found that this patient has neuropathy related to inguinal hernia repair. The genitofemoral nerve innervates the skin which is in the crease between the thigh and lower abdomen. Inguinal hernia repair may cause a lesion to the nerves in this area, with or without graft placement.  In terms of performing anesthesia, these blocks are used during procedures of the groin and lower abdomen at times. Per the medical literature, there is evidence that these blocks can be used to diagnosis pain to that location. However, in terms of pain management, there is a lack of large, retrospective, double-blind studies that show documented benefit.  Therefore, the medical literature supports the initial diagnostic block. However, there is a lack of support for the second therapeutic injection.  In sum, The first treatment with a genitofemoral nerve block was likely to have been more effective than other available modalities. The medical evidence has not established the superior efficacy of a follow-up genitofemoral nerve block. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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 Harvoni for 90 mg-400 mg tablet for 12 weeks. 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 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 non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, the requested treatment with Harvoni 90 mg-400 mg tablet for 12 weeks is medically necessary for the treatment of the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Euflexxa syringe 20 mg/2 mL (one injection to the right knee once per week for three weeks). Findings:  The physician reviewer found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. In this case, this patient has bilateral knee arthrosis and standard treatment such as with pain medications or activity modification is not for symptoms in one knee only. The patients symptoms have been present for years and are now becoming intolerable. The patient has an ulcer and is no longer a candidate for nonsteroidal anti-inflammatory medications. All told, the requested Euflexxa syringe 20 mg/2 mL (one injection to the right knee once per week for three weeks) is medically necessary for this patients painful knee arthrosis.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services provided by a neurologist who specializes in the autonomic nervous system. Findings:  The physician reviewer found that there is sufficient support in the medical literature as well in the documentation provided for the requested services in this clinical setting. Postural orthostatic  tachycardia syndrome is a prevalent form of orthostatic intolerance affecting many individuals. Its cause is suspected to be multifactorial. The medical evidence suggests that optimal therapy for this disorder is uncertain, and most of the medications used for treatment of this disorder are off label.  As a result, effective management of this condition requires someone who has experience in training and treating the disease process. The medical literature recommends a multidisciplinary care plan to be guided by a clinician who has the appropriate training and experience with the patients condition. Experienced providers have been shown to maintain quality of care. In this patients case, the patient has seen several neurologists which have addressed several elements of the patients medical condition, including nonepileptic seizures and functional movement disorder. However, this patient has not been sufficiently evaluated for her autonomic dysfunction based on the documentation provided. The documentation provided by the patient, with regards to uncovered visits with autonomic specialists, indicates a comprehensive treatment plan that addresses the patients diagnosis. Therapeutic interventions have shown to benefit this patient. As such, an evaluation of her autonomic dysfunction by a neurologist specializing in that discipline is medically indicated and is well supported in the medical literature. In sum, services provided by a neurologist who specializes in the autonomic nervous system 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 overturned. Credentials/Qualifications: The reviewer is board certified in neurology 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.