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

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Delzicol 1.2 gm tablet. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. According to a study of simulated comparison of topical and oral formulations various formulations result in release at distinct times after ingestion and locations in the gastrointestinal tract. Therefore, a patient may fail one formulation; however, achieve remission with another. Therefore, although Delzicol has failed, other mesalamine formulations may be effective.  Additionally, the patient has failed balsalazide, and has a sulfa allergy that is a contraindication to sulfasalazine, which is the other formulary alternative. For these reasons, Delzicol 1.2 gm tablet is medically necessary for the treatment of 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 reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for biofeedback. As this patient has failed first-line therapies to improve mixed urinary incontinence, she is a candidate for pelvic floor therapy assisted by biofeedback. This treatment may improve the patients pelvic floor strength and competence of external sphincter. Treatment with pelvic floor therapy with biofeedback is standard protocol with decades of supporting documentation regarding minimizing risk with statistically significant symptom relief in patients who have failed to improve after surgery. For these reasons, the biofeedback was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the biofeedback was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the services at issue were and 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:  One reviewer is board certified in urology and is actively practicing. One Reviewer is board certified in urology and is actively practicing.  One Reviewer is board certified in urology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bone stimulator for nonunion right distal radius.  Findings:  The physician reviewer found that The submitted documentation supports the requested device in this clinical setting. The presence of a 4 to 5 mm gap indicates an established nonunion of the distal radius. Per the literature, in patients with an existing nonunion or delayed union, electrical stimulation had evidence of clinical benefit over standard care on union rates at three months. Some of the literature indicates healing in 12 months without bone graft. The external electrical stimulation is likely to be beneficial in this setting. Therefore, the requested bone stimulator for nonunion right distal radius is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine at a quantity of five per day. The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity. The current medical evidence does not support chronic opiate use for the treatment of fibromyalgia and radial nerve neuropathy. Chronic opiate use for non-malignant pain is not recommended by the Centers of Disease Control and Prevention and has many side effects, including opioid-induced hyperalgesia. Therefore, morphine at a quantity of five per day is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 32-year-old female enrollee has requested authorization and coverage for an orthopedic specialist consultation.  Findings:  The physician reviewer found that The records document that this patient has evidence of lumbar spinal stenosis. A review of the current medical literature indicates non-operative as well as operative options for this medical condition. A consultation with an orthopedic surgeon is indicated to discuss treatment options focusing on non-operative options first. Based on the magnetic resonance imaging (MRI) scan findings and lack of documented response to medication, the request for an orthopedic consultation is medically necessary for evaluation and management of this patients chronic low back pain and spinal stenosis.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested reimbursement for the Zoll LifeVest. In this circumstance, there was potential for recovery of left ventricular function over time with medical therapy. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the Zoll LifeVest was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the Zoll LifeVest was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed other therapies.  She has had a trial of therapy with Otezla, with some improvement. There is no documented reason indicating why the patient cannot use the other preferred agents, including contraindications, adverse effects or intolerances. Therefore, Otezla 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 dermatology 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 Mavyret 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. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 59-year-old female enrollee has requested reimbursement for the blood test (Guardant360 biopsy-free tumor sequencing test). According to the National Comprehensive Cancer Network (NCCN), prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care to support an indication for the Guardant360 testing in this clinical setting. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. Given the peer-reviewed medical literature and current guidelines, this patient is eligible for ALK, EGFR, ROS1 and BRAF testing. Thus, the ALK, EGFR, ROS1 and BRAF portions of the blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the EGFR, ALK, ROS1, BRAF, MET, RET and HER 2 neu portions of blood test (Guardant360 biopsy-free tumor sequencing test) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remainder of the Guardant360 assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. One reviewer found that the Guardant360 testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of 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 partially 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: A enrollee has requested reimbursement for the genetic testing. Findings:  The physician reviewer found that some patients with metastatic lung cancer require molecular testing for BRAF, ALK, EGFR, and ROS1. Expanded genomic profiling panels is not supported to help direct standard therapy. Similar panels may prove useful after failure of the standard of care and primarily to help identify new potentially actionable targets and/or for clinical trial purposes. Thus, the genetic testing 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:  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for silver ring splints. Findings:  The physician reviewer found that Ehlers-Danlos hypermobility syndrome is characterized primarily by joint hypermobility, chronic widespread pains and poor health-related quality of life. A generalized hyperalgesia has been reported, possibly due to a sensitized central nervous system, implying underlying pain mechanisms similar to fibromyalgia. Treatment approaches with the highest rated subjective benefits in pain relief in survey literature have included opioids, splints, massage and heat, but the effectiveness of treatment is generally reported to be poor and evidence-based recommendations are largely lacking. Moreover, the requested proposed silver ring splints have not been demonstrated to be more effective than standard plastic finger splints. The plastic splints can be adjusted for proper fit, which was done in this patients case. In addition, the provider documented that the patient had excellent mediation of pain with the plastic splints. Thus, the requested silver ring splints are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be equipment. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 enrollee has requested reimbursement for the residential treatment center (RTC) services. This patient has a long history of eating disorder and outpatient treatment was not consistently effective in stabilizing the symptoms. She was admitted to RTC. She has exhibited symptoms of restricting, calorie counting, compulsively exercising, diet pills, laxatives, diuretics, food rituals and weight loss which were not being effectively managed in outpatient services and thus higher level of care was medically necessary. Per the American Psychiatric Association (APA) guidelines, services available for the treatment of eating disorders range from intensive inpatient settings to residential and partial hospitalization programs to varying levels of outpatient care. Pretreatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are the most important physical parameters for making this choice. Based on the review of the records, the services provided were medically necessary for this patient in order to allow for sufficient time for treatment with integration of the strategies learned during treatment and for effective discharge planning to reduce the chances of relapse. 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 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 patient has requested authorization and coverage for Nexium 40 mg DR. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients gastroesophageal reflux disease (GERD) with esophagitis. The submitted documentation supports the medical necessity of the requested medication. The American College of Gastroenterology guidelines for gastroesophageal reflux disease (GERD) recommends proton pump inhibitor (PPI) therapy for patients with GERD and esophagitis. A comparison of multiple formulary PPIs attempted by the patient, including omeprazole, lansoprazole, rabeprazole, and pantoprazole, has found no difference in control and healing of GERD, which is supported by medical literature. It is unlikely that a re-trial of these medications would be effective. Additionally, the American College of Gastroenterology guidelines for Barretts esophagus states that patients with Barrett's esophagus should receive once-daily PPI.  Current medical guidelines support continued PPI therapy when a patient has failed all other available PPIs. The patient has also reported that he has had significant improvement with Nexium. For these reasons, Nexium 40 mg DR is medically necessary for the treatment of 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 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.