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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Oncotype DX gene expression testing for evaluation of the enrollees prostate cancer. Findings:  Two physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Oncotype DX is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients. The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. In addition, the National Comprehensive Cancer Network (NCCN) guidelines suggest the Oncotype DX test to better stratify such patients with localized disease. 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 internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg for treatment of the enrollees hyperlipidemia.  Findings:  The physician reviewer found that the request for Repatha 140 mg has been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient has documented obstructive coronary disease, hyperlipidemia with LDL greater than 100 mg/dL and intolerance to both statin medication and ezetimibe. In this patient, the goal of LDL is less than 70 mg/dL. In this circumstance treatment with a PCSK9 inhibitor such as Repatha is medically necessary. Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol in spite of the highest tolerable statin and ezetimibe dose. This patient fits the latter criteria. In this setting PCSK9 inhibitors have been demonstrated in well controlled trials to be safe, effective and resulting in significantly improved cardiovascular outcomes. 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 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 parent of an enrollee has requested authorization and coverage for 12 hours per week of direct one-on-one applied behavioral analysis (ABA) services and eight hours per month of supervision for treatment of the enrollees autism spectrum disorder.  Findings:  The physician reviewer found that the request for 12 hours per week of direct one-on-one ABA services and eight hours per month of supervision is medically necessary for treatment of the patients medical condition. There is sufficient peer-reviewed literature supporting ABA as a medically necessary intervention for the treatment of children with autism and behavioral disorders. In this case, ABA therapy at the frequency of 12 hours per week of direct therapy and eight hours per month of supervision has been recommended to address non-compliance, inflexibility, outburst behaviors and elopement when asked to make low preference transitions. The patient also continues to participate in socially impairing stereotypical behaviors. There is sufficient support in the peer-reviewed literature demonstrating the correlation between treatment outcomes and treatment intensity for children with autism spectrum disorder. Based on the documentation submitted for review, the patient has made progress, but continues to demonstrate significant behavioral concerns. Thus, the patient continues to require a high level of support. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 enrollee has requested authorization and coverage for human recombinant growth hormone treatment medication Genotropin for treatment of the enrollees growth deficiency. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. A review of the growth curve shows the patients height between the 10th and 25th percentile. The patient was diagnosed with Crohns disease. It is not clear when the therapy for that condition was initiated, but it appears from the curve that GH was introduced at age 14 and a few months. There is some evidence at this growth curve for already some resumption of normal growth prior to the initiation of exogenous GH. The genetic target for this family is 68.5 inches (+/- ) 4 inches to 95% confidence. As such, any adult height above 64.5 inches would be normal for this familial context. Moreover, the patients bone age was consistent with that of a 14 year old. This bone age provides a predictive adult height to be around 66 inches, which would be considered normal for this genetic target. Therefore, the patients adult predicted height is not short enough to warrant growth hormone treatment on the basis of idiopathic short stature. The definition is commonly considered to be a height more than two standard deviations below the corresponding mean height for a given age, sex and population, in whom no identifiable disorder is present. Based on this patients record, he does not have evidence of growth hormone deficiency. The patients growth factors were both normal and the patient did not have any discernible bone age delay. Additionally, this data does not support a discernible growth retardation from the Crohns disease itself. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 left hip replacement surgery and left knee replacement surgery. Findings:  The physician reviewer found that this patient has widespread chronic pain and has undergone multiple failed surgeries which makes her a poor candidate for further surgery. Moreover, the patient is obese with a BMI between 44 and 48 in the records provided for review. Extremely overweight patients are at an increased risk of complications such as infection following joint replacement surgery. Infection following joint replacement can be a devastating and severe complication. It is medically recommended the patient undergo evaluation and treatment of her depression and lose weight before she can be considered a candidate for hip or knee replacement surgery. All told, the requested left hip replacement surgery and left knee replacement surgery are not supported as medically necessary for treatment of this patients hip and knee 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 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 of Zepatier 50 mg-100 mg for 16 weeks for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks (as requested) when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vicodin ES. Findings:  The physician reviewer found that that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The U.S. Food and Drug Administration (FDA) has approved the generic equivalents of Vicodin. In this patients case, it is reasonable to try formulary alternatives first, as there are no progress notes submitted that support the assertion that the formulary alternatives were ineffective. The medical evidence does not support the requested medication over the Health Plans alternatives in this clinical setting. All told, Vicodin ES is not medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for radiofrequency ablation for treatment of the enrollees neck pain. Findings:  Two physician reviewers found that current evidence based medical guidelines state that cervical facet joint radiofrequency neurotomy has produced conflicting evidence as to its efficacy. Criteria for the use of cervical facet radiofrequency neurotomy include a diagnosis of facet joint pain using diagnostic blocks, documented improvement in pain scores and function with diagnostic blocks, no more than two joint levels at one time, and evidence of a formal plan of rehabilitation in addition to facet joint therapy. Guidelines limit facet joint therapy to patients with non-radicular pain. This patient presents with reported complaints of neck pain and stiffness. There was documentation of positive medial branch blocks. However, there was no record of a cervical spine and neurologic examinations confirming a diagnosis of facet mediated pain. Given the significant findings consistent with a diagnosis of radiculopathy, proceeding with radiofrequency ablation is not supported by current evidence based medical guidelines and peer-reviewed literature. Final Result: The reviewers determined that the requested service 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 and 3 are board certified in orthopedic surgery and are actively practicing. Physician reviewer 2 is board certified in anesthesiology with sub-specialty certification in pain medicine 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 a colonoscopy for evaluation of the enrollee, who has a family history of colon cancer. Findings:  The physician reviewer found that the American Cancer Society guidelines for colon cancer screening state that in patients with colorectal cancer or adenomatous polyps in any first-degree relative before age 60, or in two or more first-degree relatives at any age, the first colonoscopy should be performed at age 40 and subsequent colonoscopies every five years. In this case, this patients sister had adenomatous polyps before age 60. Additionally, the submitted documentation noted both his sister and mother had adenomatous polyps. Based on the information provided for this case, the American Cancer Society guidelines would recommend colonoscopies at five-year intervals in this case, and a screening colonoscopy is overdue at this time. Therefore, the requested colonoscopy is medically necessary for the evaluation of 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 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: The enrollee has requested reimbursement for the genetic testing performed.Findings:  The physician reviewer 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 in fact thyroid cancer was via surgical excision even though the majority turn out to be benign. Afirma utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries . All told, the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three  reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for automated insulin delivery device for treatment of the enrollees type I diabetes.  Findings:  The physician reviewer found that the Medtronic MiniMed 670G automated insulin delivery device was approved by the U.S. Food and Drug Administration (FDA) in June 2016 following extensive studies related to safety and effectiveness. The system is the closest to an automated closed loop system device for insulin delivery in the management of diabetes mellitus type 1. Researchers reported that 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. This patient has diabetes mellitus type 1. In this case, even though the patients hemoglobin A1C is in target range, his diabetes control is suboptimal as demonstrated by the wide glucose fluctuations. The MiniMed 670G will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. This system will allow the patient to remain within the recommended target range most of the time. Currently the patient tests 10-20 times a day, which has allowed him to keep glucose levels under tight control. With the requested system, the CGM will communicate with the pump. He will be able to keep hemoglobin A1C to goal and while minimize hypoglycemic and hyperglycemic events. Final Result: The 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: Reviewers 1, 2 and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni for eight weeks 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees small intestinal bacterial overgrowth. Findings:  The physician reviewer found that Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones. The results are sustained for several weeks after treatment. The current medical evidence supports the requested medication in this clinical setting. 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.