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 Zepatier for 12 weeks. Findings:  The physician reviewer found that according to the most 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 or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . For these reasons, treatment with Zepatier for 12 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: The parent of an enrollee has requested authorization and coverage for otoplasty for the right ear for treatment of the enrollees prominent right ear. Findings:  The physician reviewer found that the request for otoplasty for the right ear is medically necessary for treatment of the patients medical condition. According to American Society of Plastic Surgeons (ASPS) Otoplasty is medically necessary and considered reconstructive surgery when it is performed to approximate a normal appearance, even if it does not improve function. The patient presents with evidence of bilateral prominent ears that are abnormal. Although the right side is not as severe as the left, the right ear is significantly abnormal. This is confirmed by medical examination and photographic review. The patient has a true congenital ear deformity on both sides. The patient lacks antihelical folds on both sides which is abnormal and is a congenital deformity. Thus, surgical correction is clinically indicated to correct a congenital deformity. For the reasons provided, the requested surgery is medically necessary and reconstructive in nature for treatment of the patients right ear deformity.  Final Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for nusinersen (Spinraza) intrathecal injections for treatment of the enrollees spinal muscular atrophy.  Findings:  The physician reviewer found that SMA is an autosomal recessive neuromuscular disorder characterized by degeneration of spinal motor neurons. SMA is caused by low levels of SMN protein owing to deletions or mutations of the SMN1 gene (Singh, et al). An almost identical gene SMN2, present on the same chromosome, produces a smaller, truncated protein (SMN2) because of skipping of exon 7 from translation due to translation silent C6U substitution in exon 7 of SMN2 pre-mRNA transcript. Only 10% of the SMN2 mRNAs produce full length SMN2 protein by including exon 7 in healthy individuals. A large deletion or sometimes a point mutation in SMN1 gene is responsible for SMA. Nusinersen (Spinraza) is approved by the U.S. Food and Drug Administration (FDA), and provides the potential for correction of SMN2 exon 7 splicing as a treatment for SMA. Nusinersen is an antisense oligonucleotide that targets intronic splicing silencer N1 (ISS-N1). Major evidence of its efficacy came from a sham controlled phase 3 clinical study, ENDEAR. The study was stopped early based on significantly favorable results in interim analysis and all the patients were transitioned to receive nusinersen in an ongoing open-label, phase 3 study, SHINE, to evaluate the long-term efficacy, safety and tolerability of the drug. At present there have been no published clinical trials on the efficacy of nusinersen on children with SMA1 who are already on long-term ventilation. At present the drug is FDA approved for all children who have the gene mutation in the SMN1 gene such as this patient. There is no stipulated contraindication to the drug for a patient on long-term ventilation. Based on the clinical documentation submitted for review, nusinersen (Spinraza) injections is clinically indicated for this patient. Final Result: The reviewer determined that the requested mediation 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 pediatrics and neurology with special qualification in child neurology 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 fertility preservation (ovarian stimulation, oocyte retrieval, oocyte fertilization, and storage of oocytes and/or embryos) who has been diagnosed with acute myeloid leukemia. Findings:  The physician reviewer found that egg retrieval and freezing (cryopreservation) is now a recognized option for women who have cancer and who are undergoing treatment that can render them infertile in the future by being toxic to their ovaries/eggs. This option allows these patients to have children in the future.  Technically, they are not infertile when undergoing the procedure, as the goal is to protect their gametes from the effect of the chemotherapy. This procedure is a treatment that is appropriate to discuss and offer to such patients. As noted by researchers, prior to initiating potentially gonadotoxic therapy, physicians should discuss the risk of treatment-induced infertility and possible interventions to preserve fertility. Whenever possible, all patients with newly diagnosed cancer should meet with a reproductive endocrine and infertility specialist if fertility is a concern, preferably before treatment. This treatment is supported by the American Society of Reproductive Medicine. For patients such as this, when chemotherapy is anticipated to damage or destroy the eggs, such a treatment is medically necessary. The American College of Obstetricians and Gynecologists also supports this treatment, noting oocyte cryopreservation, with appropriate counseling, is recommended for patients facing infertility due to chemotherapy or other gonadotoxic therapies. Other researchers noted that discussion of fertility preservation and appropriate referral for treatment of reproductive age (and younger) cancer patients should be a routine part of cancer care, noting that sperm and embryo cryopreservation and oocyte cryopreservation are considered standard practice. 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 obstetrics and gynecology 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 the heart scan (coronary computed tomography angiography (CCTA)) performed. Findings:  The physician reviewer found that based on the records provided the patient has a diagnosis of cardiomyopathy, no documented coronary risk factors and chest pain that is characterized as non-anginal. In this circumstance of no documented coronary risk factors and no documented chest pain that is suspicious for possible coronary ischemia further evaluation with CCTA is not indicated for this purpose and not considered standard of care. Current guidelines endorsed by several national organizations also do not consider CCTA appropriate in this clinical setting. For the reasons provided, the heart scan (CCTA) performed 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 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: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for transoral incisionless fundoplication procedure using EsophyX device for treatment of the enrollees long segment Barretts esophagus. Findings:  The physician reviewer found that the efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials. However, there is paucity of medical literature demonstrating improved health outcomes in this clinical setting. One large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months. The American College of Gastroenterology (ACG) guidelines for treatment of GERD reported that the usage of current endoscopic therapy or transoral incisionless fundoplication cannot be recommended as an alternative to medical or traditional surgical therapy. In addition, the Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing transoral incisionless fundoplication with anti-reflux surgery. Moreover, the guidelines from the American Society for Gastrointestinal Endoscopy (ASGE) do not recommend endoscopic procedures for GERD in patients with complicated GERD, which the guideline defines as dysphagia or Barretts esophagus. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective transoral incisionless fundoplication. Final Result: The reviewer determined that the requested procedure 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 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 fentanyl lollipopsFindings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has violated opiate maintenance agreements in the past.  The use of fentanyl immediate-release would be off-label since its use is limited to cancer-related breakthrough pain. There is considerable risk in providing high-dose opiates for chronic non-malignant pain. The Centers for Disease Control and Prevention guidelines state established patients already prescribed high dosages of opioidsshould be offered the opportunity to reevaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk. The medical evidence does not support the requested medication in this clinical setting. All told, the requested fentanyl lollipops are 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 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. Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 16 hours per week of applied behavioral analysis (ABA) services. Findings:  The physician reviewer found that the request for ABA therapy is not medically necessary for treatment of the patients medical condition. The records submitted for review document that the patient has autism spectrum disorder and has received ABA therapy for five years . The patients ABA service provider has recommended parent training due to the barriers to the implementation of direct intervention services. The providers recommendation for caregiver training to occur prior to consideration of re-introduction of direct intervention services is medically reasonable and appropriate in this clinical setting. As such, the request for 16 hours per week of ABA services is not clinically indicated for this patient.  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 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: An enrollee has requested authorization and coverage for Technivie (ombitasvir-paritaprevir-ritonavir 12.5 mg/75 mg/50 mg) tablets for 12 weeks. Findings:  The physician reviewer found that : According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks. However, this is recommended as an alternate regimen rather than first-line therapy. This guideline recommendation is based on the PEARL-1 trial, which demonstrated a 100% cure rate in this population . AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . As there is no documented plan to use ribavirin, the requested treatment with Technivie for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. Additionally, the AASLD/IDSA guidelines recommend the use of the Health Plans preferred medication, Harvoni, as first-line therapy. The documentation does not support a contraindication to Harvoni.  For these reasons, Technivie (ombitasvir-paritaprevir-ritonavir 12.5 mg/75 mg/50 mg) tablets for 12 weeks is not medically necessary for treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the FoundationOne test performed for evaluation of the enrollees pancreatic neuroendocrine cancer. Findings:  Two physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individual patients tumor with the hopes of identifying markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines it has not been determined if molecular markers are useful in treatment determination and prognosis other than KRAS, NRAS, and BRAF mutations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, the FoundationOne test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: 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:The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees depression, anxiety, obsessive compulsive disorder (OCD), and suicidal ideation. Findings:  The physician reviewer found that shifting the frequency of therapy and/or treatment setting is common for patients with severe OCD and consistent with the American Psychiatric Association (APA) guideline recommendations. The APA noted that the appropriate treatment setting may be the hospital, a residential treatment or partial hospitalization program, home-based treatment, or outpatient care, while daily psychotherapy may be warranted in severe cases. Additionally, the diagnosis of clinical depression accompanies this patients OCD and anxiety. This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders are notoriously difficult to treat and in general have poorer outcomes. In accordance with modern psychiatric practice, this patient has pursued treatment in less restrictive settings during the episode of illness. However, she has failed both outpatient services and partial hospitalization program (PHP) levels of care. The patient has significant mood symptoms with suicidality. She has poor self-esteem, emotional dysregulation, anxiety, family strain and difficulty leaving the home. Her medications have not been optimized. RTC level of care has been recommended by the patients providers. In the absence of adequate treatment, the confluence of self-perceptions, clinical symptoms and cognitive schemas place the patient at risk for an untoward outcome and an unnecessarily heightened risk for self-harm. As such, a premature discharge would result in undue patient morbidity and prompt re-admission, possibly to a higher level of care. Thus, treatment at the residential level of care is safe, appropriate and consistent with current medical guidelines. Final Result: The reviewer determined that the services at issue were and 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 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.