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

Nature of Statutory Criteria/Case Summary: An enrollee has requested admission to an inpatient residential chemical dependency program for treatment chemical dependency. Findings:  The physician reviewer found that he records provided for review document that this patient received inpatient detoxification which was successful in tapering her off opiates and benzodiazepines. There is no evidence of withdrawals or post-acute withdrawals. Based upon the records provided, the patient is currently medically and psychiatrically stable with regard to her comorbid health conditions, which are chronic in nature and do not require residential level of care. Further, there is no documentation of emotional, behavioral, or cognitive factors which require the intensity of 24-hour monitoring and supervision. The standard of care in this setting includes participation in a 12-step program and outpatient treatment in a setting such as cognitive behavioral therapy (CBT), which can teach coping skills to manage chronic pain. 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling for evaluation of the enrollees melanoma. Three physician reviewers found the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add more to these statistics.  By Balch staging, this melanoma would be classified as a T1a, or stage 1A, with at least an 88% chance of ten-year survival. Decision DX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a greater than 90% chance of five-year, disease-free survival), or Class 2 (with a 48 to 77% chance of five-year, disease-free survival). It is not clear how the five-year Decision DX data compares to the ten-year Balch data, and, most importantly, whether it can be used to make clinical decisions.  Based on the current medical evidence, the superior efficacy of gene expression profiling has not been established. Final Result: The 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: Reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Lyrica 25 mg, three times per day for the treatment of the enrollees headaches. Findings:  The physician reviewer found that Lyrica is an anticonvulsant medication that is U.S. Food and Drug Administration approved for the treatment of fibromyalgia, neuropathic pain associated with diabetic peripheral neuropathy or spinal cord injury, partial-onset seizures or post-herpetic neuralgia. It is used off-label for treatment of generalized anxiety disorder, hot flashes, restless leg syndrome, and social anxiety disorder. The different subtypes of headaches include chronic migraine headache, chronic tension-type headache, medication overuse headache, hemicrania continua, and new daily persistent headache. In this case, the documentation does not provide sufficient details regarding the characteristics of the daily headache. Additionally, the submitted records do not support that the patient has exhausted pharmacologic and non-pharmacologic treatment options. The use of Lyrica is not considered first-line or second-line treatment for this patients condition. Final Result: The reviewers determined that the medication at issue was not and 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 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 for Belviq XR 20 mg, once daily for treatment of the his obesity. Findings:  The physician reviewer found that Belviq XR is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater or 27 kg/m2 or greater in the presence of at least one weight-related comorbid condition. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention, including a combination of diet, exercise, and behavioral modification. Patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a body mass index greater than 30 kg/m2 or a body mass index of 27 to 29.9 kg/m2 with comorbidities, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested.  In this case, the patient has a body mass index greater than 30 and has been enrolled in a medical weight management program for more than six months with weight loss.  The records document comorbidities including pre-diabetes and hypertension. The medical evidence supports the requested medication in this clinical setting. Final Result: The reviewers 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 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 autonomic testing for evaluation of the enrollees symptoms of lightheadedness and chest pain. Findings: All three physician reviewers found that the medical literature supports the use of autonomic testing in autonomic disorders, and specifically in conjunction with tilt table testing when making a diagnosis of POTS. A study reviewed the use of autonomic testing and found it to beneficial in making a diagnosis of POTS, and leading to effective treatments. Autonomic testing is not routinely performed in most cardiac or neurologic practices. However, it adds valuable information when evaluating for autonomic neuropathy, POTS, and other autonomic nervous system disorders which may be difficult to diagnose. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 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 testing (fetal DNA testing for aneuploidy and sex determination) performed for evaluation of her pregnancy. Findings:  The physician reviewers found that the submitted documentation supports a portion of the services at issue.  Chromosomal abnormalities (aneuploidies) occur at an increased rate in women over 35 years of age, but can and do occur in younger women.  Various tests are available, but NIPT testing is now becoming routine even for women under age 35.  In this case, fetal DNA testing for aneuploidy and sex determination was performed. Per the medical evidence, the detection rates are lower and false-positive and failure rates are higher for sex chromosome abnormalities than for the autosomal aneuploidies. In this patients case, fetal DNA testing for aneuploidy was likely to have been more efficacious than other methods of evaluation. However, the superior efficacy of fetal DNA testing for sex determination has not been established. Final Result: The reviewers determined that a portion of the services 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 partially overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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 the surgical procedure, reduction mammoplasty for treatment of her macromastia. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. According to the American Society of Plastic Surgeons (ASPS) guidelines Based on the results of Level I and II Evidence, reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. In this case, the patient has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has back, and shoulder pain, as well as shoulder grooving from her bra straps. She has evidence of significant macromastia on examination detail. Her pain has failed conservative management with narcotics, activity modification and physical therapy. Her degree of resection planned is supportive of her clinical functional deficit. She would likely benefit significantly from breast reduction surgery. In sum, the patient has functional problems that are directly related to her significant macromastia. Final Result: The reviewers 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 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 Xyrem for treatment of his narcolepsy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Patients with narcolepsy have some degree of daytime sleepiness. The goal of pharmacologic therapy is to obtain normal alertness during important activities, such as working, going to school or driving.  Generally, first-line treatment of excessive daytime sleepiness is with a stimulant such as modafinil, methylphenidate or amphetamines. Xyrem is used for the treatment of continued daytime sleepiness despite the use of a stimulant.  In this case, the patient has been treated with a stimulant, Nuvigil 200 mg daily, with continued symptoms of daytime sleepiness. 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 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 modafinil tablet 200 mg for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of documentation demonstrating the patient has OSA. There is no record showing that she is being treated with optimal CPAP in a titration study and that she was compliant with the use of CPAP. There are no Epworth Sleepiness scores documenting daytime hypersomnia despite adequate treatment of OSA. In addition, there is no Multiple Sleep Latency Test (MSLT) that documents that she had a markedly decreased sleep latency with rapid eye movement (REM) sleep during the naps and that she had narcolepsy. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the coronary computed tomography (CT) scan for evaluation of the enrollees chest pain and lightheadedness. Findings: The physician reviewer found that based on the records provided this patient presented with ongoing atypical chest discomfort that has an exertional component, is reproduced on treadmill exercise and is associated with T-wave inversions on electrocardiography. In this circumstance of ongoing atypical symptoms of uncertain cause, evaluation for rare conditions such as anomalous coronary artery is reasonable, appropriate, and considered standard accepted practice in the medical community. Current guidelines consider coronary CT angiography an appropriate test to evaluate for coronary anomaly and has a preference over conventional angiography since it is less invasive with fewer risks. Final Result: The reviewer determined that the diagnostic procedure 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Botox treatment for treatment of the enrollees chronic migraine headaches. Findings: Two of the three physician reviewers found that there is sufficient support in the medical literature for the medication at issue. Botox is U.S. Food and Drug Administration approved for the treatment of migraine headaches. Migraine headaches are more complicated and more difficult to manage than episodic migraine. Migraine headaches have larger disease burden and comorbidities. Other, treatments require daily medication, often with limiting side effects. This patient has reportedly tried and failed multiple oral preventives before trying Botox therapy. In this patients case, the records indicate three to five headache days per week at baseline, or up to 20 headache days per month. When she received Botox injections, she is noted to have dropped the number of headache days, between five to ten days, a reduction of 50 to 75%. The patient also reported that the remainder of her migraines was easier to manage with Botox. This degree of benefit in this patient is consistent with what is documented in the clinical literature and medical evidence. This patient is documented to be a good responder to the Botox therapy. Final Result: The reviewer determined that the medication at issue was and 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: Reviewers 1, 2, and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heart surgery, transcatheter closure of a left atrial appendage (Watchman procedure) for treatment of the enrollees paroxysmal atrial fibrillation. Findings: All three physician reviewers found that in this patients circumstance, atrial fibrillation treatment options include continuation of anticoagulation while accepting a small bleeding risk or percutaneous left atrial appendage exclusion using a Watchman device. The Watchman device has been demonstrated to be non-inferior compared with warfarin. In addition, device placement in these trials had a high rate of significant complications (3.7-7.7%) due to pericardial effusion and procedural stroke related to thromboembolism or air embolization. The U.S. Food and Drug Administration (FDA) approved the device based on a more recent trial (PREVAIL) with lower complication rates. However, longer term follow up of that trial demonstrated an additional eight strokes, all in the arm that received the Watchman device, calling into question its long-term efficacy. Taking these additional data into account, the Watchman device failed to demonstrate non-inferiority to warfarin. Therefore, the Watchman procedure remains controversial especially in patients who are tolerating anticoagulation without bleeding side effects, without strokes and with low CHADS score, such as this patient under review. Final Result: The reviewers determined that the requested surgery 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: Reviewers 1, 2, and 3 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 Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with psoriasis affecting the scalp and intertriginous areas including gluteal cleft. He has tried and failed therapy with topical clobetasol. However, there is no documentation in the medical records of a failure of treatment trial or intolerance to any systemic agents including methotrexate, acitretin, or cyclosporine. Moreover, he has not tried and failed therapy with one of the Health Plans preferred injectable biologic agents. The medical records fail to demonstrate a reason for not using one of the formulary preferred agents. Thus, the requested Otezla is not supported as medically necessary for treatment of this patients plaque psoriasis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1b. 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. 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. The 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.