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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Avastin, Torisel, Opdivo, and Faslodex injection. The requested regimen of four medications has not been shown to improve net health outcomes in patients with metastatic breast cancer in randomized controlled clinical trials. In addition, there is a lack of data on the potential toxicities associated with this combination of medications. Moreover, the regimen is not recommended in the National Comprehensive Cancer Network (NCCN) guidelines and is not supported by major drug compendia. The use of Opdivo for breast cancer is currently the ongoing subject of clinical trials while Avastin is rarely used in breast cancer. Overall, there is a paucity of scientific data demonstrating the safety and effectiveness of this medication regimen in patients with breast cancer. Given these findings, the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Findings:  Three physician reviewers found the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.Final Result: The reviewers determined that the requested medication regimen consisting of Avastin, Torisel, Opdivo, and Faslodex injection is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies.Credentials/Qualifications: Physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 180 pills of Percocet 10/325 mg for a 30 day period. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non palliative settings. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication quantity and several recent requirements for opioid prescribing have not been documented. In this case, there is no clear objective goals and no medical evidence based rationale provided by the provider for the requested quantity of Percocet. Additionally, the records do not demonstrate that other non pharmacological forms of treatment have been performed. There is no mention of completion of behavior therapy documented despite much research to support its use.  For all these reasons, 180 pills of Percocet for a 30 day period is not medically necessary for treatment of the 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a spinal cord stimulator implant. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees complex regional pain syndrome, type 1. The submitted documentation fails to demonstrate the medical necessity of the requested device. The records note that the patient has an automated implantable cardioverter defibrillator. The placement of a conventional spinal cord stimulator is contraindicated in the presence of an automated implantable cardioverter defibrillator. While newer models of spinal cord stimulators have been found in anecdotal case reports to not trigger a discharge from the automated implantable cardioverter defibrillator, the safety of the requested device has not been established in this clinical setting. The current medical evidence does not support the requested device in this patients case. Therefore, the requested spinal cord stimulator implant is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. The submitted documentation fails to demonstrate the medical necessity of the requested device. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a treatment plan which includes Le Fort I osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, hardware removal and debridement, chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible). The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee, who has a reported history of sleep apnea, and are not reconstructive in nature. The Le Fort 1 osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, and hardware removal and debridement are not medically necessary for the treatment of this patient. This patients complaints appear to be cosmetic concerns, and it is unclear if repeat surgery will satisfy the patients concerns. The records do not include a recent repeat sleep study demonstrating the patients sleep apnea. Thus, the medical necessity of the requested Le Fort 1 osteotomy multi-segment with bone grafting, bilateral sagittal osteotomy with bone grafting, and hardware removal and debridement has not been established.With regards to chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible), the records do not support the medical necessity of these requested services. However, this patients condition constitutes an abnormal structure of the body. The patient has been diagnosed with mandibular hypoplasia. The etiology of maxillofacial skeletal deformities may be either congenital or acquired. This condition may be evident at birth or may manifest during subsequent growth and development. The requested surgery will be performed to create a normal appearance to the extent possible. Additionally, the proposed surgery is likely to result in more than a minimal improvement in the appearance of the patient. Therefore, the requested chin repositioning (revision with hardware removal), and HA Md (hydroxyapatite Avitene) length/body (possible) is reconstructive in nature.  Final Result: The reviewer determined that a portion of the requested services is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan. Findings:  Three physician reviewers found that Leiomyosarcoma is a type of sarcoma that commonly arises from soft tissue and occasionally arises from the bone. It accounts for approximately 7% of sarcomas. It is most commonly treated with chemotherapy, and if possible, complete resection. Adjuvant radiation therapy may also be needed. In this patients case, although she was noted to be in remission, there are residual masses in the sacrum and T10 regions. The advantage of PET/CT scanning over routine CT scanning is that PET can demonstrate increasing metabolic activity in a lesion that appears to be chronic or scarred. In this patients case, the medical evidence supports evaluation with PET scanning. Thus, the requested PET scan is likely to be of greater benefit than other available options for evaluating this patient. Final Result: 3 of 3 reviewers determined that the requested services are 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 1, 2 and 3 are board certified in diagnostic radiology 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 reimbursement for the radiofrequency ablation (RFA) of the sacroiliac (SI) joint. In the documentation available for review, the provider states the patient had two days of pain relief after doing an injection with steroids. However, the literature indicates that RFA may be effective if performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage. This patients records do not include documentation that this protocol was followed. In addition, the most recent physical examination is not specific to SI joint dysfunction. Finally, there is no documentation of a home exercise program, physical therapy, or other conservative, non-invasive and non-pharmacological, treatment options in the records provided for review. Therefore, the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the RFA of the SI joint performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 liquid biopsy. Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines advise broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component in improving the care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Molecular profiling such as with Guardant360 is indicated in this clinical setting. Thus, the Guardant360 liquid biopsy was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that since standard guidelines do not include Guardant360, the Guardant360 liquid biopsy was not 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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 prostatic urethral lift (PUL) procedure. The PUL is a novel, minimally invasive approach to treating benign prostatic hyperplasia (BPH) that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials including prospective sham controlled randomized studies have shown that the UroLift PUL procedure is safe and effective in relieving lower urinary tract symptoms due to BPH without significantly compromising sexual function. The long-term durability of PUL has been demonstrated with maintained outcomes reported at 48 month follow-up. However, the efficacy of UroLift PUL in patients with large median lobe and prostate size greater than 80 grams is unknown as these patients were excluded from the UroLift studies. Hence, this patient is not considered a good candidate for UroLift PUL procedure as he has a large median lobe and prostate volume of 84 grams. As such, the requested PUL procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested PUL procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and can stratify whether a melanoma is high risk for metastasis or not. This test has shown some accuracy determining risk of metastasis in thin to intermediate thickness melanomas like in patients case. However, what to do with the results of the test are indeterminate, at this time. There is limited scientific evidence permitting conclusions concerning the effect of this test on health outcomes and there is not enough published data to support its routine use. The treatment of this patient would not change based on the results of the examination. Moreover, the test is not considered routine standard of care for treatment of patients in this clinical setting. The current standard of care would be to perform a wide local excision. For these reasons, DecisionDx-Melanoma assay was not likely to have been superior over the available methods of evaluating this patients medical condition.Final Result: All three reviewers determined 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:  All three reviewers are board certified in dermatology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for percutaneous tibial nerve stimulation. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition.Findings:  There is support in the medical literature for the requested services in this clinical setting.  Percutaneous tibial nerve stimulation is considered to be an appropriate salvage therapy for this patient.  This patient underwent urethral sling surgery which subsequently failed. The patient underwent removal of the urethral sling followed by urethrolysis procedure. Currently she is on medication with good improvement. The record notes that she has tried behavioral therapy, dietary changes, physical therapy, and multiple pharmacotherapy. At this time, the patient has failed multimodal primary and secondary treatments for her condition. The studies support the use of percutaneous tibial nerve stimulation to be an appropriate salvage therapy. Therefore, based on the documentation provided as well as the medical literature, percutaneous tibial nerve stimulation is likely to be more beneficial than the standard treatment options available for treatment of this patients medical condition.Final Result: Two of the three reviewers determined the requested services are 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:  All three reviewers are board certified in urology and are 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture. Findings:  The physician reviewer found that In reviewing the records available, there is no documentation that the patient has undergone an acupuncture trial. Given the patients continued symptoms despite previous care including physical therapy, medications, yoga and self-care, an acupuncture trial for pain management and function improvement is reasonable. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Also, a recent randomized controlled trial comparing usual care to acupuncture plus standard therapies found that at 24 months, patients treated with acupuncture with standard therapies were more likely to report 12 months decreased pain and were less likely to require use of pain medication. Consequently, the requested acupuncture is supported as medically necessary for treatment of this 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 reviewer is board certified in oriental 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: A female enrollee has requested authorization and coverage for Mavyret 100-40 mg tablets for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines recommend that non-cirrhotic treatment naive genotype 2 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 99% cure rate with eight weeks of treatment. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablets 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.