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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Valcyte for treatment of her medical condition.  Findings:  Two physician reviewers found that the requested medication is not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Chronic fatigue syndrome (CFS) has not been confirmed to be the result of an infection. There have been associations with infections but the causal nature has not been established in chronic fatigue syndrome. Pathogens such as mycoplasma and other bacteria have also been associated with CFS. The treatment plan indicated that the provider could not rule out an infectious trigger. CFS has been associated with viruses such as EBV and HHV-6 but not reliably reproducibly with any infectious pathogen. A recent review of research focusing on the various treatment strategies for chronic fatigue syndrome evaluated 35 treatment trials with regard to the benefit and harm of the various interventions. The authors concluded that counseling, behavior therapies, and graded exercise therapy improved measures of fatigue, function, global improvement, and work impairment; counseling and behavior therapies also improved quality of life. All other therapies including valganciclovir provided insufficient strength of evidence. In addition valganciclovir is not U.S. Food and Drug Administration (FDA) approved for the treatment of HHV-6. For these reasons, Valcyte is not likely to be more beneficial for treatment of the patients medical condition compared to standard therapy.  Final Result: Two reviewers determined that the requested medication is 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 reviewers are board certified in internal medicine with sub-specialty certification in infectious disease 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 breast tomosynthesis for treatment of her medical condition. Findings: Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists in the interpretation of both screening and diagnostic mammograms especially in cases of heterogeneously dense tissue as in this case. The tomographic nature of the technique allows radiologists in many cases to separate dense glandular elements from mass or architectural distortion as well as the characterization of indeterminate masses to assess the need for intervention. This has resulted in a decrease in callbacks and increase in detection of small cancers.  Thus, this patient likely had more benefit with the addition of tomosynthesis to her diagnostic study than if she had had two-dimensional imaging only.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health condition. Findings: The physician reviewer found that residential treatment center program services level of care was not medically indicated for this patient during the dates in question. According to the documentation submitted for review, the patient was not in active withdrawals and had mild post acute withdrawal syndrome (PAWS). The patient was not a threat to herself or others. The patient was cognitively intact and independent. The patient was medically and psychiatrically stable. The patient was motivated and actively engaged in the recovery process. The patient had a stable sober support system. She could have continued her treatment at an intensive outpatient program level of care. Given the above, the services at issue were not medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with a history of plaque psoriasis and is requesting treatment with Otezla. However, there is no documented intolerance to or lack of efficacy of treatment with methotrexate or acitretin. Additionally, the patient has not tried and failed treatment with either phototherapy or Stelara. There are no documented contraindications to use of either of these treatment modalities. Given that the patient has no documented contraindications to the therapies listed above, the request for coverage of Otezla 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 physician 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 Harvoni for treatment of her hepatitis C virus. 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 or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of his medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Subsys has not been established. According to the documentation submitted for review, the patient has been treated with multiple high dose opioid medications. There is a lack of documentation demonstrating improved function or attempted weaning of these medications. In addition, the patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Given the above, the requested medication 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-certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a lab test (infectious disease HCV 6 assays) for evaluation of her medical condition.  Findings:  Two physician reviewers found that hepatitis C recurrence in this case had already been excluded, and liver-related blood studies proved normal. Prior liver biopsy showed no fibrosis, and no contemporary imaging testing was provided to support concern for either fatty liver or for occult fibrosis to warrant FibroTest. The use of FibroTest is generally reserved for assessment, by non-invasive means, to measure the degree of liver fibrosis in patients with active viral hepatitis C, or in those with biopsy-proven non-alcohol steatohepatitis (NASH) and neither condition of which is supported by the patients available record. As such, the lab test (infectious disease HCV 6 assays) was not likely to be more beneficial for evaluation of the patients medical condition than already performed standard assessments. Final Result: Two reviewers determined that 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 internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an annual genetic homocysteine lab test. Findings:  The physician reviewer found that there is a lack of utility in testing homocysteine or folate based on this patients genetic test result. The American College of Medical Genetics (ACMG) recommends against testing for polymorphisms in the MTHFR gene, including in those with a known family history of these changes. In fact, the ACMG included MTHFR testing in their Choosing Wisely campaign, highlighting the recommendation that this testing not be done. There is a suggestion to consider testing of fasting homocysteine in those homozygous for the C677T polymorphism, as those with two copies of this change are at higher risk for elevated homocysteine. However, this patient does not have two copies of this polymorphism. In addition, the patient has had repeated homocysteine measurements that have been normal. Given the above, the requested services are not clinically indicated for evaluation of the patients medical condition.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 physician reviewer is board certified in clinical biochemical genetics, 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 breast tomosynthesis for the evaluation of her breast examination. Findings:  Two physician reviewers found that current studies support the addition of digital breast tomosynthesis (DBT). The findings of these studies indicate that the use of DBT reduces false positives and increases cancer detection when compared to 2D Full Field Digital Mammography (FFDM, 2D) mammography alone. 3D allows better characterization of possible masses, spiculation, and architectural distortion. The above statement is strongly supported by data in the studies by both Skaane and colleagues and Ciatto and colleagues. In this case, the provider indicated that the patient also had additional risk factors.  For these reasons, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for the evaluation 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 radiology with sub-specialty certification in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested neuropsychological testing for evaluation of his behavioral health condition.    Findings: The physician reviewer found that neuropsychological testing is indicated to evaluate conditions resulting from organic causes, such as traumatic brain injury, brain tumor, stroke or progressive neurological disorders. None of these are present in this patients case. In addition, the information that the referring psychiatrist was seeking could have been obtained through far less onerous evaluations. Specifically, the patient could have had psychological testing specifically to evaluate his attention, mood and anxiety for the purposes of establishing/confirming his psychiatric diagnoses. Such testing would most likely have been accomplished within a few hours and provided the psychiatrist with the information he needed on a timely basis. Secondly, in order to evaluate the patients communication needs, and especially given his history of previous speech therapy, a more appropriate referral for this concern would have been to a speech therapist. Such a specialist could have both evaluated the patient and initiated any treatment if it were deemed necessary. For the reasons provided, the services at issue were not medically necessary for evaluation of the patients medical condition.  Final Result:  The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Subsys for the treatment of his medical condition. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The records do no demonstrate that non-opioid treatment options have been exhausted. Behavior therapy has not been done, despite research to support its use. In addition, optimization of all non-opioid medications has not been documented.  The records demonstrate that tolerance has taken place.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. The records do not demonstrate a plan in place to monitor this patient with the new increase in medications.  There is a lack of support for the requested medication in this clinical setting. All told, Subsys is not medically indicated 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 physician 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 magnetic resonance imaging (MRI) of the knee for evaluation of her medical condition.Findings: The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. MRI of the knee as recommended by the treating orthopedist is indicated to determine whether an arthroscopic debridement of the joint is likely to be beneficial versus a more extensive procedure such as total knee arthroplasty. The utilization of both x-ray and MRI is a standard approach in making an appropriate clinical decision as to whether a meniscal debridement or removal of loose bodies may provide a likely benefit and follows the standards of care. In addition, MRI in the face of degenerative osteoarthritic conditions is indicated in order to assess not only the joint surfacing but also the adjacent subchondral bone to rule in or out occult fractures or bone marrow bruises with bone marrow MRI changes. Given the above, MRI of the knee has been established as medically necessary for treatment of the patients medical condition.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 physician 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 Orthovisc injections for treatment of his medical condition.   Findings: The physician reviewers found that Orthovisc injections are not medically necessary for treatment of the patients medical condition. There is a lack of support in the evidence based literature supporting the requested services. In addition, there are possible complications, which may jeopardize future total knee arthroplasty. A meta-analysis of the efficacy of visco supplementation performed by Rutjes and colleagues included a total of 89 trials involving 12,667 adults with knee osteoarthritis. The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. In sum, the request for Orthovisc injections to be utilized in the management of the patients medical condition is not medically necessary given the lack of support in the evidence based literature.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 physician 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.