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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco and Diazepam for treatment of the enrollees chronic low back pain. Findings: The physician reviewer has found that based on the documentation submitted for review, the patient has had long-term opioid use and has been prescribed benzodiazepines medication on a long-term basis. He describes symptoms of withdrawal from both medications when unavailable. These medications have been prescribed as part of his care. Guidelines for opioid and benzodiazepine dependence recommend a slow taper when these medications are discontinued. In terms of Norco, a suggested taper is 10% every two to four weeks. In general, weaning of benzodiazepines such as diazepam takes more time than opioid withdrawal. Although there is no currently universal weaning protocol available, one current recommendation of tapering is about 1/8 to 1/10 of the daily dose every one to two weeks. An alternative weaning schedule is to decrease by 10% a week or 5 mg (whichever is smaller). The first 50% of weaning is generally smoother than the last 50%. When the final 25% to 35% of dose is reached it is suggested that the decrease in dose be lowered to 5% at a two-week interval. The rate of withdrawal should be individually tapered based on signs and symptoms and visits should occur on a weekly basis during weaning or more often if clinically indicated. Discontinuing either Norco or Valium without an appropriate plan for tapering risks withdrawal symptoms. For the reasons provided above, the request for Norco and diazepam is medically necessary until an appropriate plan for tapering is devised and implemented. Final Result: The reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for microprocessor ankle/foot. Findings:  Two physician reviewers found that the request for microprocessor ankle/foot is likely to be more beneficial for treatment of the enrollee's medical condition than any available standard therapy. Studies report on the contributions of active ankle and knee assistance to the walking mechanics of transfemoral amputees using the powered prosthesis. Powered ankle knee prosthesis provide active knee and ankle assistance effecting the mechanics of transfemoral amputees. The authors assessed ankle stiffness during swing initiation and active powered plantarflexion in three transfemoral unilateral amputees at walking speed.  The authors investigated the effect of the powered ankle plantarflexion combined with active flexion of the knee in terminal stance and in other portions of the gait cycle. The authors found that eliminating active knee swing initiation or powered plantarflexion was linked to increased compensations of the ipsilateral hip joint during the subsequent swing phase. In this case, the patient is a traumatic amputee. The requested microprocessor controlled device will likely improve the velocity of his gait and allow him to do step over as well as step up and down stairs and minimizing the likelihood of falls. In sum, the proposed device incorporates microprocessor technology and the benefits will provide decreased energy expenditure, improved function particularly in stair climbing and descending, and in the prevention of falls. Final Result: As such, 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 orthopedic surgery 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 AndroGel 20.25mg/1.25 gram (1.62%). Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Guidelines, such as the European Association of Urology, International Society of Sexual Medicine and Endocrine Society recommend two morning testosterone levels below reference range prior to initiation of therapy. In this patients case, there is inadequate documentation to support the diagnosis and type of hypogonadism. Moreover, the time of initial diagnosis is unknown. Recordings of two morning testosterone levels below reference range, prior to initiation of therapy, are not documented. In addition, symptoms of hypogonadism are also not documented. Most guidelines recommend treatment in carefully selected patients who have classical androgen deficiency symptoms. Lastly, documentation supporting continuous monitoring of testosterone replacement therapy is not available. Most guidelines also recommend monitoring laboratory findings (at least testosterone, hematocrit, prostate specific antigen and lipid profile) at three, six, and twelve months after initiating testosterone replacement therapy, and then annually thereafter. For these reasons, the requested coverage for AndroGel 20.25mg/1.25 gram (1.62%) is not medically necessary for treatment of this patients medical condition. 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 urology 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 OrthoPak osteogenesis stimulator (bone growth stimulator).Findings:  The physician reviewer found that there is support in the literature for the device at issue in this clinical setting. During the last few decades, electrical current stimulation has gone from an investigational modality to an accepted method of treatment to assist with bone healing. Electrical stimulation is based on the premise that mechanical stress applied to bone results in the generation of electric potentials. The studies have shown that the generation of an electrical field at the fracture site should have the ability to enhance bone formation. In this patients case, the provider noted that three months post-surgery, there was no union of the first tarsometatarsal fusion.  A bone growth stimulator was utilized at that time with good outcome.  The other option would have been additional surgery with bone grafting and plating. As such, the bone growth stimulator was effective in treating this patient. Final Result: The reviewer determined that the device at issue was 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 reimbursement for monitored anesthesia care for management of the enrollees pain during her colonoscopy. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. Also, While Monitored Anesthesia Care may include the administration of sedatives and/or analgesics often used for Moderate Sedation, the provider of MAC must be prepared and qualified to convert to general anesthesia when necessary. Additionally, a providers ability to intervene to rescue a patients airway from any sedation-induced compromise is a prerequisite to the qualifications to provide Monitored Anesthesia Care. The medical necessity of MAC takes into consideration many aspects of care including but not limited to the patients ASA classification. The selection and appropriate amount of sedation and/or anesthesia required for colonoscopy is not one size fits all. This is where the clinical judgment of the practitioner comes into play. The ASA practice guidelines and position statement on the use of propofol as noted in the documentation states The society believes that the involvement of the anesthesiologist in the care of every patient is optimal  non-anesthesia personnel who administer propofol should be qualified to rescue patients whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anesthesia.  Propofol is a short acting sedative anesthetic. The onset of action is dose dependent and on average is 30 seconds. The duration of action lasts 3 to 10 minutes depending on the dose. The administration of propofol for a colonoscopy is considered a standard method of anesthesia. The administration of propofol necessitates a practitioner qualified to rescue the patient should they enter a state of general anesthesia. Final Result: The reviewer determined that the services at issue were medically necessary for the treatment of this patient.  Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 genotype testing. Findings:  Three physician reviewers found that the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization is not yet ready for mainstream clinical application as the relatively small, short-term studies to date have not been replicated on a larger scale.  According to the American Psychiatric Association (APA), Current evidence provides limited support for the utility of pharmacogenetic testing, while trusted psychiatric reference texts do not recommend genetic testing for cases involving routine medication management. Additionally, there was no clinical data provided to support genetic testing.  The documentation did not include the patients longitudinal illness burden and extent of impairment, psychosocial stressors and medical comorbidities, if any. Further, there was no psychiatric assessment, interpretative summary, clinical formulation or treatment history. As such, it cannot be inferred that the patient had exhausted standard treatments available to treat his anxiety and schizoaffective disorders. In sum, genotype testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three Physician reviewers are board certified in psychiatry 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 Vemlidy 25 mg for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir (Viread and Vemlidy) compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate, which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including osteopenia and renal disease. For this reason, Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. 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 reimbursement for the residential treatment center (RTC) level of care services he received. Findings:  The physician reviewer found that the patient continued to meet criteria for RTC level of care services during the period in dispute. The records demonstrate that he had not developed coping strategies or the ability to maintain sobriety if he were to be discharged to a lower level of care. In addition, there was continued family dysfunction such that the patients home environment would likely not have afforded the structure and boundaries needed for the patient to avoid a relapse if he were discharged from the 24-hour RTC facility. All told, the RTC level of care services provided were medically necessary for treatment of this patients behavioral health issues. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for the gene test, Afirma gene expression classifier for evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewers found the cytopathology of the 3.17 cm thyroid nodule was consistent with a follicular lesion of undetermined significance (FLUS). The risk of malignancy is 5-15% in FLUS. The Bethesda System recommends a repeat biopsy for this type of nodule. The newest 2015 American Thyroid Association's guidelines state that for nodules with AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision making. If the genetic test is suspicious, the risk of malignancy increases to approximately 40%. In this patients case, the result of the Afirma testing was benign. This information was important to determine the decision whether to perform thyroidectomy or not and may prevent the need for a diagnostic hemithyroidectomy. There are multiple peer reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. The test is in vitro, which confers no physical risk to the patient. The sample is obtained at the same time of the fine needle aspiration biopsy, and no additional procedure is needed. The test is also included in the algorithm for diagnosis of thyroid nodules by the National Comprehensive Cancer Network 2016 guidelines. In sum, the gene test, Afirma gene expression classifier was likely to have been superior to the other available options in the evaluation of this patients medical condition. Final Result: Two of three 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 number one, two, and three are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and 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 the genetic testing for the evaluation of the enrollees indeterminate thyroid nodule. Findings:  The physician reviewer found that a fine needle aspiration (FNA) biopsy was suggestive of a follicular lesion of undetermined significance. A specimen was subsequently sent for Afirma gene classifier analysis. While a fine needle aspiration (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 of the cases turn out to be benign.  The Afirma thyroid FNA analysis 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. This test is very sensitive and has a high negative predictive value. A negative Afirma result is suggestive of a benign nodule and can therefore preclude surgical procedures. Final Result: The reviewer determined that the testing 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: The 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Foundation One gene testing for evaluation the enrollees metastatic melanoma.Findings:  Two physician reviewers found that diagnostic features used to direct treatment and prognosis of melanoma include location of primary, stage of disease, tumor thickness, ulceration and mitotic rate. Initial evaluation of metastatic melanoma also includes determination of the lactate dehydrogenase level and molecular profiling. Molecular profiling has become more relevant with the development of several targeted therapies. Recent data has demonstrated that patients with specific mutations in BRAF and KIT bare tumors more susceptibility to BRAF inhibitors and tyrosine kinase inhibitors, respectively. According to the National Comprehensive Cancer Network (NCCN) guidelines, genetic analysis is described as screening for mutations in BRAF, and in the appropriate clinical setting, C-KIT. Thus, current guidelines support tumor molecular profiling as part of clinical care and treatment for metastatic melanoma. The information provided eliminated the treatment option of a BRAF inhibitor, but demonstrates a potential role for therapy based on his KIT mutation. Final Result: Two 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: All three physician 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.