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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for sinus surgery. Findings:  The physician reviewers found that the medical records fail to demonstrate the superior effectiveness of the services at issue.  The clinical notes document symptoms of recurrent acute rhinosinusitis with multiple episodes of the preceding six months. The physical examination and CT imaging confirmed evidence of nasal septal deviation, mucous membrane thickening within the maxillary sinus ostia and some hypertrophy of the inferior turbinates.  However, the patient had no evidence of frontal sinus disease based on the imaging studies or clinical examination and physical findings of the frontal sinus on the right side.  Of note, balloon sinus dilation was not mentioned preoperatively as a potential surgical intervention.  Balloon sinus dilation may be an effective method for limited sinus disease only.  The technique does not offer the ability to eradicate and remove extensive polyps.  At present, functional endoscopic sinus surgical techniques are considered the surgical treatment of choice for the management of chronic rhinosinusitis refractory to medical management. Thus, the services at issue were not likely to have been more efficacious than other treatment options. Final Result: 3 of 3 reviewers determined that the services at issue were 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: All three physician reviewers are board certified in otolaryngology 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 Zovirax cream. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The medical evidence indicates that topical Zovirax (acyclovir) cream is only of modest benefit for the treatment of herpes labialis.  Studies noted the following, Acyclovir cream has been available for the treatment of herpes labialis in numerous countries outside the United States for over a decade. Evidence for its efficacy comes from a few small clinical trials conducted in the 1980sAcyclovir cream did not prevent the development of classical lesions (progression to vesicles, ulcers, and/or crusts). Given the frequency of needed application and modest effect of topical agents, oral antivirals are recommended over topical.  Studies noted, There is also evidence that prophylactic oral ACVmay reduce the frequency and severity of recurrent attack of herpetic infection in immunocompromised patients, but the optimal timing and duration of treatment is uncertain and can vary in different situations. In this patients case, there is no documented herpes simplex virus type 1 infection but there is presumed infection.  Moreover, the studies show that there is no contraindication to the use of oral medications in this patients case, although the patient had reported some gastrointestinal upset with oral agents. The medical literature recommends a trial of oral agents given the improved response. As such, the request for Zovirax cream is not medically necessary for 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 internal medicine with sub-specialty certification in rheumatology 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 female enrollee has requested reimbursement for the venous angioplasty procedure. Findings:  Three physician reviewers found that there is sufficient support in the peer-reviewed literature for the procedure at issue in this clinical setting. Secondary chronic venous disorders usually follow an episode of acute DVT. Most occluded venous segments re-canalize over the first 6 to 12 months after an episode of acute DVT, leading to chronic luminal changes and a combination of partial obstruction and reflux. With respect to venous obstruction, iliocaval angioplasty and stenting has emerged as the primary treatment for proximal iliofemoral venous obstruction with surgical bypass assuming a secondary role. As such, the venous angioplasty procedure performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the procedure 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: Physician reviewers number one and three are board certified in vascular surgery and are actively practicing. Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. All three 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 LINX CPT code 0392T. Findings:  Three physician reviewers found that the LINX device has been approved by the U.S. Food and Drug Administration for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  In this patients case, he is symptomatic, but there is no objective evidence of esophagitis and his available record documents subjective response to conventional medical therapy. As such, he cannot be considered medically refractory to acid blocker drugs. Thus, LINX CPT code 0392T is not likely to be more beneficial than the available standard therapy for treatment of this patients medical condition. Final Result: 2 of 3 reviewers determined that the requested services are 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 intravenous (IV) ceftriaxone sodium per 8.0 units daily 250 mg for 90 days.  Findings:  The physician reviewer found that per the Infectious Diseases Society of America (IDSA) guideline, treatment with ceftriaxone is recommended for patients with neurolyme. This patients records do not include documentation of cerebrospinal fluid (CSF) infection with Lyme disease. In addition, the IDSA guidelines recommend treatment for a maximum of 30 days. Extended regimens have not been adopted into mainstream guidelines. Accordingly, the requested IV ceftriaxone sodium per 8.0 units daily 250 mg for 90 days is not supported as 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 internal medicine with sub-specialty certification in infectious diseases 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 40 hours per week of applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that a study evaluated the relationship between ABA treatment intensity and treatment outcomes for individuals with autism spectrum disorder. The authors reported a strong relationship between treatment intensity and mastery of learning objectives, where higher treatment intensity predicted greater progress was demonstrated. In this case, the patient appears to have made progress in many areas, but she continues to demonstrate impairment in several areas including poor eye contact, poor attention to stimulus and sensory defensiveness, outburst behaviors consisting of high pitched screams and aggression in the context of global developmental delays. These persistent struggles are making it increasingly difficult for her to be successful in more generalized environments. The Health Plan has authorized 24 hours per week of ABA therapy, which is on the low end of what is typically recommended for optimal response. Several studies have recommended 25 or more hours of weekly ABA to ensure optimal outcomes. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30-40 hours of treatment per week. Given the sufficient support in the peer-reviewed literature, 40 hours per week of ABA is medically necessary for treatment of the patients medical condition. 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 physician 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx gene test. Findings:  Three physician reviewers found that recent literature supports the use of genetic testing of the uveal melanoma tumor in order to stratify the tumors into high and low risk for systemic metastasis. In addition, the DecisionDx test has become part of the standard of care in this patient population. The main clinical benefit of the DecisionDx test is that it determines how closely to monitor and screen the patients for metastasis. Another consideration is that although there is no therapy today to reduce the risk of metastasis, this may become available in the future. Therefore, it is important to obtain the genetic information about the tumor when available, which in the case of uveal melanoma, may only be in the early stages. For these reasons, the DecisionDx gene test performed was 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 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 ophthalmology 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 Forteo. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested medication in this clinical setting. The provider had prescribed Forteo to restore plasticity to the bone prior to the patient undergoing surgery. The patient has not been treated with bisphosphonates in the past. While there are some studies as to the use of Forteo for the treatment of fractures, these studies are limited. In addition, the use of Forteo in preparation for surgery, as is proposed in this patients case, has not been indicated in large studies. For these reasons, Forteo 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to a surgical weight loss specialist. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity for the requested services in this clinical setting. Bariatric surgery is currently reserved for treatment of morbid obesity. However, in this patients case, a diagnosis of morbid obesity is not confirmed by her BMI. The guidelines for bariatric surgery is supported when BMI is 40 kg/m2 or 35 kg/m2 with a serious comorbid condition such as diabetes, hypertension or sleep apnea. The patients BMI was noted as 38.3 kg/m2. There is no documentation that she is diagnosed with comorbid conditions of diabetes, hypertension or sleep apnea. Therefore, in this patients case, she currently does not meet the criteria for bariatric surgery as recommended by the guidelines. Therefore, the requested referral to a surgical weight loss specialist is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 HP Acthar gel, 80 units twice weekly. Findings:  The physician reviewer found that, as noted in the medical literature, Acthar gel is indicated for treatment of FSGS. While it has been demonstrated to have limited success in treating steroid resistant FSGS, there has been response in some patients. As Acthar gel has been requested for this patient following failure of standard therapies and has been shown to be successful in similar patients, there is an indication for its use in this clinical setting. Given this support, the requested HP Acthar gel, 80 units twice weekly is medically necessary for treatment of this patients FSGS. 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 nephrology 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 rituximab infusion.  Findings:  The physician reviewer found that  there is sufficient support for the requested services in this patients case.  Rituximab maintenance has become somewhat common in the treatment of chronic lymphocytic lymphoma.  A study included 67 patients with chronic lymphocytic leukemia.  The authors noted that maintenance rituximab improved the quality of the response to initial therapy, and yielded a prolonged progression-free survival.  Another study performed a randomized study of 263 patients with chronic lymphocytic lymphoma.  After initial therapy, patients were randomized to either observation alone or maintenance rituximab.  Progression-free survival was 12 months longer in the rituximab maintenance group.  The medical evidence supports the requested services in this patients case.  All told, the requested rituximab infusion is medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician reviewer  is board certified in internal medicine with sub-specialty certification in medical oncology 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 Nucynta ER 200 mg tablets. Findings:  The physician reviewer found that the medical records document that this patient has a neuropathic pain condition. In addition, the provider reports that the patient has failed treatment including at least two opioids as well as one anticonvulsant. The patients pain is reportedly under good control with the Nucynta. Nucynta has demonstrated efficacy as published in the peer-reviewed medical literature as an option for neuropathic pain syndromes. Studies noted that in a blinded randomized controlled study, Nucynta had a minimal impact on bowel function (non-inferior to oxycodone/naloxone PR) and was associated with significantly lower incidences of constipation and vomiting and significant improvements in quality-of-life measure. Studies also reported that Nucynta showed benefit for treatment of neuropathic pain including diabetic peripheral neuropathy pain. Studies found that Nucynta had a positive role in the treatment of neuropathy. Since this patient has failed other agents but has demonstrated benefit previously with the Nucynta, the requested Nucynta ER 200 mg tablets are supported as medically necessary. 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica 100 mg. Findings:  The physician reviewer found that Lyrica 100 mg is medically necessary for treatment for the patients chronic neuropathic pain. Gabapentin and pregabalin have similar safety and efficacy in the medical literature for chronic neuropathic pain. According to studies, pregabalin has a multidimensional effect across a range of disorders that have of a pathogenesis involving a central nervous system response of abnormal hyperexcitability. The use of pregabalin in these complex and difficult-to-treat conditions is associated with rapid and durable clinically significant improvements in several outcome measures relating to core symptoms, including pain, anxiety and sleep, and improvements in overall health status and health-related quality-of-life. In this case, the medical records document that the patient has physical exam findings and imaging studies consistent with neuropathic pain due to complex regional pain syndrome. Additionally, there is documentation showing that the patient failed other anticonvulsant medications in the same class due to severe adverse reaction to gabapentin. Given that the patient is exhibiting neuropathic or radicular pain and failed trials of similar medications such as gabapentin, Lyrica 100 mg has been established as medically necessary for this patient. 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine 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.