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 Nexium 40 mg twice per day for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings: The physician reviewer found that compared with brand name medications, generic formulations may contain additional inactive ingredients such as dyes. Although differences in efficacy between generic medications and brand name medications have not been widely demonstrated, differences in tolerance and adverse effects may be present. The records document that this patient has already failed one generic formulation of Nexium. Therefore, the requested coverage of brand name Nexium is supported as medically necessary in this case. However, the use of Nexium 40 mg twice daily rather than once daily is not supported. The American College of Gastroenterology guidelines recommend twice-daily therapy when once-daily therapy is insufficient to control GERD symptoms and esophagitis. Despite this recommendation, the dose of esomeprazole 40 mg twice daily (80 mg per day) is not recommended and is not approved by the U.S. Food and Drug Administration (FDA). Higher doses of proton pump inhibitors can be associated with adverse effects such as osteoporosis (Fraser, et al). Furthermore, the patient has not reportedly been treated with Nexium 20 mg twice daily. For these reasons, the requested treatment with brand name Nexium 40 mg daily is supported as medically necessary for the treatment of this patients GERD, but Nexium 40 mg twice daily is not supported as medically necessary.Final Result: The reviewer determined that a portion of the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 authorization and coverage for BRAC Analysis Rearrangement Test for evaluation of the enrollee, who has a history of ductal carcinoma in situ. Findings:  The 3 physician reviewers found that the current medical evidence supports the requested services in this case.  This patients family history is suggestive of a breast/ovarian cancer syndrome.  BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers.  BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers.  In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect.  In this patients case, the requested BRAC Analysis Rearrangement Test is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. In this patients case, her breasts were reported as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Three reviewers have determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of botulinum toxin injections for treatment of the enrollees temporal headaches, myofascial pain dysfunction syndrome and grinding of teeth.  Findings: The physician reviewer found that the medical literature does not support the requested services in this clinical setting. There have been various treatment modalities of MPD ranging from conservative therapies such as heat, physical therapy, and splint therapy to more invasive measures including oral medications, direct muscle injections, or dry needling. In regards to treatment with Botox injections, there is a lack of controlled clinical trials showing the benefits of Botox injections to patients with MPD. Given the lack of randomized clinical trials to establish therapeutic effects and protocols, the requested Botox injections for treatment of this patient, are not medically necessary.Final Result: The reviewer determined that 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 oral facial and maxillary 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 continuous glucose monitor for treatment of the enrollees hypoglycemia.  Findings: The physician reviewer found that there is sufficient support for the requested device in this clinical setting.  The literature almost exclusively references use of continuous glucose monitoring in the context of diabetes mellitus.  This patient does not have diabetes mellitus.  Rather, she has frequent episodes of severe symptomatic hypoglycemia with no distinct pattern or association and no known diagnosed condition following comprehensive evaluation.  Despite the lack of a diagnosis, however, her body is subject to these episodes of hypoglycemia and the potential morbidity associated.  She lacks hypoglycemia awareness, particularly at night when her blood sugar rapidly and randomly drops.  This increases the likelihood of delay in intervention.  Although she does not have diabetes mellitus, the use of a continuous glucose monitor nevertheless provides both diagnostic and therapeutic benefit.  The data collected will allow for pattern analysis, and the immediate feedback will allow for swift intervention to prevent morbidity.  All told, the requested continuous glucose monitor is medically indicated 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 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 Norco and MS Contin for treatment of the enrollees chronic low back pain and neuropathy.  Findings: The reviewer found that Felicilda-Reynaldo notes that opioid risk mitigation tools should be part of practice and when patient safety issues are identified such as lack of compliance, lack of adherence to prescription, or aberrant use, opioids should not be continued. Cheung and colleagues noted that opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor for aberrant behavior or drug misuse and opioid rotation may be considered, when loss of response or adverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose. Opioids should be tapered when patient safety risks are identified. Overall, peer-reviewed guidelines support opioids with ongoing review and documentation of pain relief, functional status, appropriate medication use, and side effects. Pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, and intensity of pain after taking the opioid, how long it takes for pain relief, as well as how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. This patients medical records report chronic pain and progress notes document ongoing opioid risk mitigation tool use. However, the records do not indicate failure of conservative treatment in support of opioid therapy. Congruent with current guidelines, chronic opioids are not indicated for treatment of this patients chronic pain. All told, the requested Norco eight tablets per day and MS Contin one tablet per day are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medications 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested trigger point injections for treatment of the enrollees plantar fasciitis and neuroma. Findings: The physician reviewer found that the enclosed information and pertinent medical guidelines support the medical necessity of the requested trigger point injections for treatment of this patients medical condition. It is well documented in the enclosed progress notes that this patient presents with pinpoint palpable pain to bilateral heels at the plantar fascia origin. Pinpoint palpable pain is also noted to the third interspaces in both feet. The current medical literature and standard of care supports the use of localized cortisone/steroid injections to symptomatic painful areas in this clinical setting. This is especially appropriate given the patients painful proximal plantar fasciitis and Mortons neuroma. All told, the requested trigger point injections are medically necessary for treatment of this patients plantar fasciitis and neuroma.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 podiatry 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 StimWave spinal cord stimulator surgery for treatment of the enrollees pain.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of chronic pain.  The services at issue are not an established treatment for axial back pain.  Riogard and colleagues reported on a small case series of patients with axial pain with some good results.  However, this study has not been replicated.  Song and colleagues also reported on spinal cord stimulation for axial pain, but the results have been mixed.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested StimWave spinal cord stimulator surgery is not medically indicated for the treatment of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan infusions for treatment of the enrollees myasthenia gravis. Findings: Two reviewers found that in the peer-reviewed medical literature, Iorio and colleagues noted that myasthenia gravis is an autoimmune disorder of the neuromuscular junction caused by circulating antibodies specific for the post-synaptic acetylcholine receptor or, in a minority of cases, for the muscle-specific tyrosine-kinase and the low-density lipoprotein receptor-related protein 4. A wide range of symptomatic and immunosuppressive treatments is currently available for myasthenia gravis patients with variable outcome. However, most immunosuppressive treatments are characterized by delayed onset of action and in some cases are not sufficient to induce stable remission of the disease. Lebrun and colleagues noted that Rituxan has demonstrated efficacy in limiting relapses in myasthenia gravis. Rituxan is a chimeric monoclonal antibody specific for the CD20 B-cell surface antigen. Recent studies have provided evidence that Rituxan may be an effective treatment for patients with myasthenia gravis who are refractory to standardized immunosuppressive therapy. Blum and colleagues reported that Rituxan at a dose of 1 g appears to be beneficial in the treatment of patients with severe myasthenia gravis. The records demonstrate that this patient has myasthenia gravis and has failed multiple therapies. Since the current medical literature supports the use of Rituxan in cases of myasthenia gravis refractory to other first-line therapies, the requested Rituxan infusions are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that 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 physician reviewers are board certified in internal medicine with sub-specialty certification in neurology 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 Tafinlar and Mekinist for treatment of the enrollees adenocarcinoma of the mullerian origin. Findings: The physician reviewer found that there is a lack of support for the requested medication regimen in this clinical setting.  Patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials.  This may be particularly relevant for very rare cancers where even phase II studies may be not be effectively conducted due to poor accrual.  Recently, it has become important to identify mutations that may be amenable to targeted therapy.  This patients tumor had mutational profiling which revealed a gain of function BRAF mutation, v600e, which has been described in melanoma, colon cancer, lung cancer, and hairy cell leukemia, among others.  Mekinist is an inhibitor of MEK kinases approved for use in metastatic melanoma with mutant BRAF.  The MEK kinases are within the same pathway as RAS and BRAF.  Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling, such as the tumor under discussion.  However, there is not sufficient experience of this combination in ovarian cancer compared to colon cancer.  All told, Tafinlar and Mekinist are not medically necessary for the treatment of this patient.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.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage for Afirma gene testing for evaluation of the enrollees thyroid nodule. Findings: Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  Afirma gene testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma gene testing was likely to have been superior over other methods of evaluating this patient.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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

An enrollee has requested reimbursement for the three-dimensional (3D) digital breast tomosynthesis performed.  Findings:  The physician reviewer found that this technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the 3D digital breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the diagnostic procedure 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: the physician reviewers 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.