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 full abdominoplasty and bilateral lipectomy/thighplasty for treatment of the enrollee who has had rashes, intertrigo and yeast infections due to excess skin. Findings: The physician reviewer found that as noted, the patient has well-documented functional issues related to recurrent rashes of the upper and lower abdomen. However, this medical condition is not clearly documented for the patients thighs. It is unclear if the same open sores and chronic fungal infections affect the medial thighs. The photographs do not show evidence of a significant condition, as the skin-to-skin contact appears mild. Also, the providers letter appears to address only the upper and lower abdominal pannus but not the thighs. Further, the literature notes that only in rare circumstances will thigh lifts be needed to treat functional abnormalities. According to the records, this patient does not require treatment for a functional abnormality. Further, the excess skin of the patients thigh does not constitute an abnormal structure of the body. Based on the overall documentation provided, bilateral lipectomy/thighplasty is not medically necessary and is not reconstructive in nature. In summary, a portion of the requested services is medically necessary and is reconstructive in nature. Specifically, full abdominoplasty is medically necessary and reconstructive in nature while bilateral lipectomy/thighplasty is not medically necessary and is not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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 Norditropin flexpro 5 mg/1.5 mL pen for treatment of the enrollee, who has symptoms of growth hormone deficiency. Findings: The physician reviewer found that the patient has short stature, poor growth velocity, low growth factors, and delay in bone age. He has a congenital morphological abnormality of his pituitary gland known to be associated with GH deficiency, and he has evidence of another pituitary hormone deficiency, central adrenal insufficiency. The patient meets standard criteria for classic GH deficiency, and it is medically necessary for him to receive GH therapy until epiphyseal fusion. The patient does not require formal provocative GH testing to diagnose GH deficiency in the setting of poor growth, a morphological abnormality of the pituitary gland, and biochemical testing supporting 2 pituitary hormone deficiencies. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 Zepatier 1 tablet daily 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Accordingly, treatment with Zepatier 1 tablet daily 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: An enrollee has requested authorization and coverage for an anterior hip revision using the same manufacturer of prosthetic as the enrollees current prosthetic. Findings:  The physician reviewer found that the documentation provided supports the medical necessity for the requested services in this clinical setting. This patients clinical diagnosis includes component loosening complicated by a severe maximal rating of pain by the patient. The Orthopaedic Knowledge Update (OKU) noted studies, which compared anterior versus the posterior lateral approach. The studies demonstrated equivalence in terms of component positioning and hospital stay but the comparative studies demonstrated early higher complication rates in patients who have been treated with a direct anterior approach. Modes of failure after total hip arthroplasty include infection, loosening, instability and periprosthetic fracture. Instability has been established as the most common cause of revision hip arthroplasty. In this patients case, the provider noted the instability of the components. This may result from malpositioning or periprosthetic complications or aseptic loosening and osteolysis. The details of motor failure for this patient will be determined at the time of revision arthroplasty as well as whether the same components used in the initial surgery are contraindicated. In consideration of the medical references and the documentation submitted, it is clinically appropriate for this patient to undergo a revision total hip arthroplasty. Accordingly, anterior hip revision, using the same manufacturer as the patients current prosthetic, for treatment of his medical condition is medically necessary.Final Result: The reviewers 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aubagio 14 mg tablets.Findings:  The physician reviewer found that : Aubagio is U.S. Food and Drug Administration (FDA) approved therapy for relapsing forms of multiple sclerosis, and it is typically used for early and mild forms of multiple sclerosis. The Health Plan has three formulary multiple sclerosis medication, all of which are injectable. In this specific case, since the patient has physical issues with being able to give herself an injection, an oral agent or intravenous agent would be indicated. Given the lack of options for using non-injectable agents, and this patients reported difficulty with self-injection, the requested Aubagio 14 mg tablets are medically necessary. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ultrasound and magnetic resonance imaging (MRI)for evaluation of the enrollee who recently had an abnormal mammogram study. Findings:  The physician reviewer found that while breast MRI has an important role in both screening and diagnostic settings, the documentation submitted does not support the medical necessity of the requested services in this clinical setting. In the last several years, the American Cancer Society (ACS) and the American College of Radiology (ACR), have established guidelines for the appropriate use of breast MRI. As per the ACS/ACR guidelines, those screening indications include screening for the high risk patient, screening the contralateral breast in a patient with a recently diagnosed breast malignancy, and screening in patients with breast augmentation. In this patients case, she does not meet the criteria for being at high risk for developing breast cancer as defined by ACR/ACS guidelines. Overall, MRI studies of the breast are highly sensitive but have a relatively low level of specificity. The medical literature does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound. It is common for an MRI report to state that there are subtle abnormalities that are not indicative of definite tumor and a follow-up MRI is recommended. When there is a clearly defined mass, sonography is excellent in distinguishing a cystic from a solid lesion, but in the clinical setting of suspicious calcifications, a negative or a positive sonogram will not change the need to do a biopsy. The ACR has established appropriateness criteria for the evaluation of breast lesions, and they are clear that If suspicious calcifications are present in the mass, biopsy is indicated regardless of stability or margination. Though a mass was not detected in this patient, the new development of calcifications is enough to warrant a biopsy. 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 reviewer is board certified in diagnostic radiology 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 hydrocodone-acetaminophen (Norco), surgery of the neck and computed tomography (CT) scan of the neck.  Findings:  The physician reviewer found that according to the North American Spine Society (NASS), the criteria for neck surgery require cervical radiculopathy/myelopathy, or fracture, tumor, infection, or severe cervical stenosis with radiculopathy, or herniated nucleus pulposus and failure of conservative management. This patient presents with chronic neck pain. He has no symptoms or signs of a cervical radiculopathy nor cervical myelopathy. He has not responded to some conservative treatment, but has not exhausted all available conservative options. The records do not document the patient has worn a collar, used a TENS unit, or increased his nortriptyline 10 mg to therapeutic doses by 10 mg increments to 50 mg per day. Further, a psychological evaluation could help rule out non-anatomic causes of his pain. Thus, he fails to fulfill criteria for surgery. With regard to the requested CT scan, the patient has already received a CT scan and MRI scan. There is no need to repeat either of these studies based on the guidelines from the American College of Radiology (ACR). He fails to fulfill criteria for the requested CT scan. With regard to the request for Norco, this patient has been appropriately advised that narcotic usage is not appropriate for chronic nonmalignant pain as recommended by the Centers for Disease Control and Prevention (CDC) guidelines. Final Result: The reviewer determined that the requested medication and services are not medically necessary for evaluation or treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurological 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: An enrollee has requested authorization and coverage for budesonide (Entocort EC) for treatment of the enrollees ulcerative colitis. Findings:  The physician reviewer found that The documentation provided supports the medical necessity for the requested medication in this clinical setting. Corticosteroids are effective for the treatment of ulcerative colitis. The medical studies have shown that budesonide is unique in that it preferentially treats the gastrointestinal tract, avoiding the systemic side effects of steroids such as prednisone. Various forms of budesonide including Entocort EC are effective in small bowel disease, while other forms are targeted to the distal colon and rectum. Entocort primarily affects the ileum and ascending colon. These areas of the bowel including the ileocecal valve are inflamed in this case, and the medication has helped this patient. Final Result: The reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam therapy (CPT code 77523) 45 visits for treatment of his gastric cancer. Findings:  Three physician reviewers found that there is scant data on proton therapy for treatment of gastric cancer and limited data supporting the use of proton therapy for esophageal cancer. While proton therapy has a role in the treatment of some cancer patients, this option is not clinically beneficial for treatment of all patients. Moreover, the most recent National Comprehensive Cancer Network (NCCN) guidelines do not address proton therapy for gastric or esophageal cancer. For gastric cancer, treated with palliative intent, proton therapy has no clear clinical benefit. There is a paucity of data to support its use, and while there are some dosimetric advantages, there are other dosimetric disadvantages.  For this patient, any potential dosimetric advantage clinically may not be meaningful. Given that IMRT or conventional 3-dimensional radiation could be used for treatment in this patient, proton beam therapy is not likely to be beneficial. Final Result: The reviewers determined that the services at issue are 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: Reviewer 1, 2, and 3 are board certified in radiation oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Perjeta (J9306) 420 units every 21 days for treatment of the enrollees triple positive invasive ductal carcinoma of the breast. Findings:  Three physician reviewers found that Perjeta is an antibody directed against the cluster of HER genes, which are overexpressed in HER2 positive breast cancer. Though similar to Herceptin, its activity is different, leading to interest in the combination of Perjeta with Herceptin. Randomized studies have shown that using the combination of antibodies, along with chemotherapy, is superior in outcome to using only Herceptin, in patients with metastatic breast cancer. The National Comprehensive Cancer Network (NCCN) indicates that the combination of the antibodies, along with chemotherapy, has become standard of care in the neoadjuvant situation. However, the remaining issue is whether a patient should be treated with the combination of antibodies, as opposed to Herceptin alone, in the adjuvant situation, as in this patients clinical situation. Overall, there is a lack of data to demonstrate that adding Perjeta to Herceptin in the adjuvant situation provides additional clinical benefit. Until such convincing data becomes available, there is no proven clinical benefit from adding Perjeta to Herceptin in adjuvant therapy. Final Result: The reviewers determined that 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: 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: 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 Optune E0766-electrical stimulator device for treatment of her brain cancer (glioblastoma). Findings:  Three physician reviewers found that anaplastic astrocytoma and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy. The standard of care is to resect the GBM maximally followed by treatment with temozolomide.  Most GBM tumors recur and then the treatment options are limited.  This patient has exhausted all these options. In 2011, the U.S. Food and Drug Administration (FDA) approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent GBM. The approval was based on a randomized clinical study where 237 patients got either Optune versus best standard of care chemotherapy (including bevacizumab). This study noted that there was no difference in overall survival between the two modalities. Moreover, the National Comprehensive Cancer Network (NCCN) have now included Optune device in their treatment flow charts. Follow up analyses have backed up the results on its efficacy. Recently, the FDA expanded the indication for Optune to include newly diagnosed GBM when used along with temozolomide and radiation therapy. This decision was based on a randomized clinical trial where 695 patients were analyzed for Optune in combination with temozolomide compared with temozolomide alone. The Optune device, in combination with the standard treatment, resulted in prolonged overall survival.  Final Result: The reviewers determined that the device at issue was and is 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and is 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: An enrollee has requested breast reduction surgery for treatment of her bilateral breast hypertrophy.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case.  She has well-documented severe symptomatic macromastia. Her symptomatology, examination detail and review of the photographs are supportive of this. She has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has neck and back pain as well as shoulder grooving from bra straps. She has evidence of severe macromastia on examination detail and review of the photographs. Her pain has failed conservative management with nonsteroidal anti-inflammatory drugs. She would likely benefit significantly from breast reduction surgery. Breast reduction is a well-known procedure that directly addresses functional compromise. Final Result: The reviewers 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 number two 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.