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

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Norditropin FlexPro 10 mg injections for treatment of the enrollee who has a history of nontoxic multinodular goiter, gastric ulcer and obesity.Findings:  The physician reviewer found that growth hormone deficiency (GHD) is a medical condition in which the body does not produce enough growth hormone (GH).  Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance.  Growth hormone deficiency is also appreciated to be a factor in this increased mortality from cardiovascular disease.  GH replacement therapy can provide a number of measurable benefits to GH deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In patients with known hypothalamic or pituitary disease, providers can establish the diagnosis of GH deficiency with high sensitivity and specificity when there are three or four additional pituitary hormonal deficiencies or a subnormal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. Although this patient seems to exhibit some signs and symptoms, which may be consistent with growth hormone deficiency, she does not effectively meet the necessary criteria to establish this diagnosis.  Her IGF-1, while on the low side, is within normal limits and the submitted records do not appear to indicate any other pituitary hormone deficiencies.  Therefore, Norditropin FlexPro 10 mg injections are not medically necessary for the treatment of this 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 the gene test (BRAF mutation analysis) for evaluation of the enrollees stage IV metastatic adenocarcinoma of the sigmoid colon.Findings:  Three physician reviewers found that BRAF mutation testing is the standard of care for patients with colon cancer and are recommended by the National Comprehensive Cancer Network (NCCN) guidelines. BRAF activating mutations, most of which occur in codon 600 (V600E), occur in less than 10% of sporadic colorectal cancer and are a strong negative prognostic marker for both early stage and advanced/recurrent tumors in non-MSH-H tumors. In MSI-H tumors, in which most of the BRAF mutations occur, the presence of a mutation does not have the same adverse prognostic significance. The available data also support the view that BRAF V600E mutations confer resistance to anti-EGFR therapy. Final Result: All three reviewers determined that 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 overturned. Credentials/Qualifications: All three physician reviewers 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: enrollee has requested authorization and coverage for deep brain stimulation. Findings:  The physician reviewer found that The American Psychiatric Association (APA) recommends that somatic therapies such as deep brain stimulation should be considered only after first- and second-line treatments and well-supported augmentation strategies have been exhausted. Per the guidelines, first-line treatments are CBT, selective serotonin reuptake inhibitors (SSRIs), and clomipramine. Second-line treatments include augmentation with other medications such as antipsychotics, stimulants, modulators of glutamate receptor, and other agents like ondansetron and naltrexone. A published review by international experts on strategies for the treatment of OCD recommends the use of neurosurgical treatments such as deep brain stimulation for patients with severe symptoms that have not responded to available medications and psychotherapies. As noted in the medical records provided for review, this patient has failed multiple first-line and second-line treatments for OCD. The patient has a documented history of treatment refractory OCD. Final Result: The 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 psychiatry 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 authorization and coverage for bilateral nerve decompression for treatment of the enrollees migraine headaches.Findings:  Three physician reviewers found that currently, nerve decompression has not been validated in the peer-reviewed medical literature as an effective treatment option in occipital neuralgia or migraine. The standard surgical procedure for refractory occipital neuralgia is C2 radiofrequency or rhizotomy. However, this patient has had minimal standard treatment for his migraines or occipital neuralgia. Thus, his condition cannot be considered refractory. Therapies such as gabapentin, topiramate, and beta blockers, or Botox have not been attempted for treatment of chronic migraine have not been utilized.  Final Result: Three reviewers determined that the requested service 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: Two physician reviewers are board certified in internal medicine with sub-specialty certification in neurology and are actively practicing.  One physician reviewer is board certified in internal medicine with sub-specialty certifications in neurology and pain medicine 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: An enrollee has requested reimbursement for DecisionDx-Melanoma Assay testing for evaluation of the enrollees malignant melanoma. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma Assay should not be used outside of a clinical trial. Moreover, the use of this type of testing is not the standard of care in the treatment of the patients melanoma. The testing at issue is not expected to impact the treatment or outcome of the patients melanoma. Final Result: 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: All three physician reviewers are board certified in dermatology 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: A male enrollee has requested authorization coverage for general anesthesia for treatment of the enrollees dental procedure (dental extraction).Findings:  The physician reviewer found that The request for general anesthesia service is not medically necessary for treatment of the patients medical condition. The medical literature cites rare but significant risks associated with any type of anesthesia, as well as treatment alternatives to general anesthesia. According to the medical records provided for review, the patient is a healthy 17-year-old with no medical indication for general anesthesia. Given that the patients physical examination does not demonstrate a clinical indication for general anesthesia, the requested general anesthesia is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially upheld. Credentials/Qualifications: The reviewer is board certified in dentistry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision DX Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewers found that the records do not indicate that sentinel node sampling was performed in this case.  All told, Decision DX Melanoma testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: All three 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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 authorization and coverage for esophageal sphincter augmentation device (LINX procedure for treatment of the enrollees gastroesophageal reflux disease.Findings:  Two physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Current Opinion in Gastroenterology, concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval. One peer-reviewed journal published a letter stating that there are 11 reports of endoscopically confirmed LINX erosion through the esophagus in the U.S. Food and Drug Administration (FDA) Adverse Events database. Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended.  Final Result: Two physician reviewers determined that the requested services 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as a first-line regimen for non-cirrhotic genotype 3 patients, regardless of prior treatment. This is based on trials including ASTRAL-3, which showed a high cure rate of 98%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Epclusa is medically necessary for treatment of the 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 authorization and coverage for Roux-en-Y gastric bypass surgery for treatment of the enrollees obesity. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Not all patients will be determined to be appropriate candidates for bariatric surgery despite meeting body mass index metrics to meet definition for morbid obesity. Although this patient is an adult with morbid obesity, she was not determined to be an appropriate candidate after completion of a multidisciplinary evaluation at this time. Per the records, she was not found to have obtained psychological clearance. Therefore, the risks of surgery outweigh the potential benefits at this time. All told, the requested Roux-en-Y gastric bypass surgery is not medically necessary 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 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 an additional 10 transcranial magnetic stimulation (TMS) treatments.  Findings:  The physician reviewer found that based on the Clinical TMS Society Consensus Review and Treatment Recommendations, the majority of patients who receive acute benefit from TMS therapy do so within four to six weeks. The meta-analysis by Berlim and colleagues indicate that the average treatment length for TMS sessions is 12.6. In this case, the patients MADRS score remained unchanged through 30 treatments of TMS. Given that the patient has had modest progress in 30 TMS sessions, it is unlikely that 10 additional TMS sessions will be of benefit. 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 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 authorization and coverage for ketamine infusion for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the documentation available for review, there is reference to failure of multiple standard treatments of pain. However, not all non-opioid medications classes have been optimized or tried. There is no evidence that other anticonvulsant medications or antidepressants have been failed or are contraindicated. Also, the patient may respond to maintenance therapy at a higher dose of Cymbalta. In addition, there is no mention of recent physical therapy and a home exercise program. Further, while it is noted the patient had subjective relief from the ketamine infusion, no objective functional improvement is documented. With regard to the medical literature, the effectiveness of ketamine infusions for post laminectomy syndrome is lacking. Current data suggest that ketamine infusion response lasts about three weeks for back pain and is not a long-term treatment strategy. Final Result: The reviewer determined that the requested service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for computed tomography (CT) scan, positron emission tomography (PET) scan, biopsy and pathology for evaluation of the enrollees neck pain, hearing loss, rhinitis, and nasal polyp. Findings: The physician reviewer found that the medical literature, PET/CT imaging can have a substantial impact on intended management when used for three targeted diagnostic indications: (1) determining whether a suspicious lesion is cancer; (2) detecting an unknown primary tumor site in a patient with confirmed or strongly suspected metastatic disease; and (3) detecting a primary tumor site in a patient with a presumed paraneoplastic syndrome. PET/CT plays a crucial role in the diagnosis and management of patients with head and neck squamous cell cancer (HNSCC). The major clinical applications of this method include diagnosing an unknown primary tumor, identifying regional lymph node involvement and distant metastases, and providing prognostic information. In addition, PET/CT can be used for precise delineation of the tumor volume for radiation therapy planning and dose painting, and for treatment response monitoring by detecting residual or recurrent disease. This patient has been followed for GERD and recurrent H. Pylori infections. His symptoms include a burning taste but there was no documentation of dysphagia or hoarseness or difficulty with speech, which are common in head and neck cancers. Moreover, there was no documentation of constitutional symptoms suggesting tumor burden. He has been evaluated with more than one nasopharyngoscopy and EGD, and although there have been findings of arytenoid edema which is suggestive of GERD and diffuse gastritis, no mucosal abnormalities suggestive of tumor infiltration or mass effects have been described. Prior imaging has been negative. Finally, there is no documentation of cervical lymphadenopathy to suggest an unknown primary tumor. 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 otolaryngology 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.