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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Synvisc-One injection and related services and prospective authorization and coverage for Euflexxa/Synvisc injection services for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is support for a portion of the services at issue in this clinical setting. This patient presents with chronic right knee pain. Clinical examination findings are consistent with the diagnosis of right knee osteoarthritis. The patient reported that reasonable conservative treatment, including medications, activity modification, and exercise have failed to provide adequate symptom relief. It was noted that prior viscosupplementation injections had provided significant sustained relief for six months. The patient underwent viscosupplementation with six months of relief, and repeat injections. Evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery and may be reasonable when there is improvement in symptoms for six months or more. Given the previous response to the Synvisc-One injection, a previous injection was medically indicated. However, there is insufficient documentation provided to support the medical necessity of current or future viscosupplementation injections for this patient. There is no discussion regarding the efficacy of a Synvisc-One injection relative to the duration of relief to support a repeat injection currently and in the future. Therefore, a previous Synvisc-One injection and related services were medically necessary for treatment of this patients knee pain but the requested future viscosupplementation injections are not medically necessary. Final Result: The reviewer determined that a portion of the services at issue was 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Findings:  Three physician reviewers found that the National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma Gene Assay should not be used outside of a clinical trial setting. The use of this type of testing is not considered to be standard of care in the evaluation of this patients melanoma. Moreover, the DecisionDx-Melanoma Assay is not expected to impact the treatment or outcome of this patients melanoma. All told, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 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: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the cervical spine for evaluation of the enrollees headache. Findings:  The physician reviewer found that neck pain and migraines can be triggered secondary to cervical disease. However, the medical literature indicates that conservative care which includes non-steroidal anti-inflammatory drugs (NSAIDs), narcotic medications, physical therapy, home exercise program and/or chiropractic care for at least six weeks can be beneficial in reducing neck pain and subsequent headaches. The documents provided for review do not demonstrate that the patient has completed six weeks of conservative care. In addition, the neurological examination does not support myelopathy as there is no documentation of weakness or pathologic reflexes. Based on the clinical documentation provided for review, the requested MRI of the cervical spine has not been established as medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Pentasa. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this patients case. Per the medical evidence, 5-aminosalicylate medications such as Pentasa can be effective for the treatment of Crohns disease. Although several mesalamine derivative medications are available for the treatment of inflammatory bowel disease, each formulation results in release at distinct times and locations in the gastrointestinal tract. Pentasa is different from the alternative medications in the pH and location at which it acts. Pentasa is effective in the small intestine, which is appropriate for Crohns disease with small bowel involvement, as in this patients case. Unlike Pentasa, the formulary mesalamine alternatives are released in the colon. The other formulary alternative, budesonide, is a corticosteroid and not an appropriate long-term, first-line therapy for Crohns disease.  Additionally, the patient is known to have had bone loss, which is a known adverse effect of corticosteroids, when using Entocort (budesonide) in the past. All told, the requested medication Pentasa is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cologuard screening for evaluation of the enrollees risk of colon cancer. Findings: The physician reviewer found that the request for Cologuard screening is medically necessary for evaluation of the patients medical condition. Cologuard is U.S. Food and Drug Administration (FDA)-approved to test for colon cancer in average-risk patients such as this patient, proved 92% sensitive for detection of colon cancer, and can detect most adenomas if they have high-grade dysplasia (Imperiale, et al). The test is recommended by the American Cancer Society guidelines. Although colonoscopy has the highest recommendation from the U.S. Preventive Services Task Force, the patient has provided a valid relative contraindication to colonoscopy. The patient will be unable to undergo bowel preparation without significant adverse symptoms and distress. For these reasons, the request for Cologuard is supported as medically necessary for colorectal cancer screening. For the reasons provided, the requested service is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 orthotics for treatment of the enrollees bilateral foot pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment in this patients case. The records document cavus foot structure with painful metatarsalgia. Orthotics are utilized to correct foot pathology. Numerous pathologies respond well to repositioning the weight-bearing foot with the use of orthotics. In this case, the patient has severe forefoot pain due to a cavus foot structure. Cavus feet tend to be rigid, and these types of foot structures force patients to place a significant amount of pressure to the forefoot, causing pain. Orthotics are utilized to offload significant pressure from the painful area of feet and support the arch and forefoot to allow for pain-free ambulation. The current medical evidence supports the requested equipment in this clinical setting. All told, the requested orthotics are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for fluorodeoxyglucose-positron emission tomography (FDG-PET) scan for evaluation of the enrollees memory loss. Findings:  The three physician reviewers found that there is a growing body of literature supporting the use of fluorodeoxyglucose (FDG-PET) in this clinical setting. Neuroimaging has come to play an important role in the diagnosis and characterization of dementia. This technique can help guide treatment and aid avoid ineffective therapy. Neuroimaging can be divided into structural imaging (computed tomography, MRI) and functional imaging (FDG-PET imaging, functional MRI). FDG-PET is a biomarker for neuronal degeneration in dementia and when used appropriately, can add valuable information to the patients clinical workup. FDG-PET can show characteristic reductions in neuronal activity in patients with probable Alzheimers disease in certain regions of the brain and therefore help to confirm the diagnosis. According to the American College of Radiology appropriateness criteria, FDG-PET of the brain may be used as a problem solving technique in differentiating dementias. Metabolic PET imaging has been proven to provide greater diagnostic accuracy when compared with clinical evaluations without the use of functional imaging of this type. Additionally, FDG-PET shows distinct patterns of metabolism in the brain and in conjunction with a patients clinical data, can aid in the early characterization and subsequent management of dementia as well as provide prognostic information. The studies have shown that FDG-PET of the brain can also assist in differentiating between mild Alzheimers disease versus non-Alzheimers dementias. In cases where the anatomic imaging or MRI is normal, such as in this case, functional imaging or FDG-PET is the next step in the patients dementia workup. In this particular case, FDG-PET would aid in the diagnosis of the patients dementia and could help to guide further treatments. For these reasons, the requested FDG-PET scan is likely to be more effective than the standard modalities of evaluating this patient medical condition. Final Result: The three physician reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for the treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the physician reviewer found 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 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Zepatier 50-100 mg tablets is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of the enrollees thyroid cancer. Findings:  two of three physician reviewers found that The testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has metastatic medullary thyroid cancer that has been treated with multiple tyrosine kinase inhibitors as well as immunotherapy. The patient has exhausted available standard therapies. Next generation sequencing with FoundationOne can provide possible targets for which clinical trials may be available. Therefore, the FoundationOne gene testing provided was likely to be more beneficial for evaluation than available standard therapy to guide decision making.Final Result: The 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: 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 genetic testing. Findings:  Three physician reviewers found that there is a lack of support for the superior efficacy of the genetic testing except for the BRCA1 and BRCA2 genetic testing portion of the services at issue. According to National Comprehensive Cancer Network guidelines, a patient with breast cancer should be BRCA tested only under certain circumstances. The guidelines would recommend BRCA testing for this patient if she has a relative (first-second, or third degree relative) with ovarian cancer. The patient reported family members who have been diagnosed with breast and ovarian cancers. However, the genetic testing at issue involved a multigene panel, which included BRCA as well as other multiple gene abnormalities. Though these other gene mutations are of interest and are being studied, they have as yet not been found to be significant enough to be the basis for any clinical decisions for the patient or their family members. Such testing is not included in the guidelines from the major organizations. Therefore, the BRCA1 and BRCA2 portion of the multigene panel  received would likely have been more beneficial for the evaluation this patient, but the other portions of the multigene panel would not likely have been more effective. Final Result: 2 of 3 reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: All three 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 are 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 computed tomography scan (CAT) for evaluation of the enrollee who has a history of hyperlipidemia. Findings: The physician reviewers found that while the research in coronary CAT for calcium scoring has advanced over last few years, it has not been proven with any long term study or trial that it is better in predicting adverse outcome when compared with other ways of risk stratification and therefore, it is still considered to be investigational. Cardiac CAT scan for calcium scoring is a well-established method for detecting atherosclerotic calcification involving coronary arteries. It has been established that the coronary calcium burden is related to adverse outcome. However, what continues to be the matter of debate is how it can predict outcome when compared with other laboratory and non-laboratory data. There are several different ways to stratify risk for coronary events including patients symptoms, risk factors, lifestyle, and laboratory data. There is lack of research comparing calcium scoring CAT against other factors that can stratify risk because this type of comparison is difficult to perform between these variables. In 2009, the United States Preventive Services Task Force (USPSTF) issued recommendations on using nontraditional risk factors in coronary heart disease risk assessment. The USPSTF concluded that the evidence is insufficient to assess the balance of benefits when using this modality. They determined that the evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined. As such, USPSTF recommended against screening asymptomatic men and women with no history of coronary heart disease. In sum, CAT scan will not likely be more beneficial than other standard methods of assessing coronary disease in this patient.Final Result: The reviewers determined that the requested services are 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 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.