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 Vosevi tablets 400/100/100 mg, for an additional 12 weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that patients with Childs B cirrhosis who are ribavirin-ineligible, as this patient is due to anemia, and genotype 3 hepatitis C should be treated with sofosbuvir/velpatasvir tablets for 24 weeks. However, for genotype 3 patients who have failed NS5A therapy, as in this patients case, the guidelines recommend the addition of Vosevi to overcome resistance, based on the POLARIS trial. Guidelines from the European Association for the Study of the Liver state that in difficult-to-cure patients with NS5A resistance, Vosevi can be used for 24 weeks for retreatment. For these reasons, the requested treatment with Vosevi for an additional 12 weeks (to complete 24 weeks of treatment in total) is appropriate for treatment of this patients hepatitis C infection. Thus, the requested Vosevi tablets 400/100/100 mg, for an additional 12 weeks is medically necessary for treatment of this patients medical condition. 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 authorization and coverage for Flexitouch pneumatic compression device.Findings:  Three physician reviewers found the Flexitouch pneumatic compression device is indicated for the treatment of lymphedema, primary lymphedema, post-mastectomy edema, edema following trauma and sports injuries, post-immobilization edema, venous insufficiencies, treatment and assistance in healing stasis dermatitis, venous insufficiency ulcers, or arterial and diabetic leg ulcers. Studies have shown that compression devices can reduce lymphedema effectively. These types of devices can be recommended for short-term use in combination with a lymphedema treatment program for reducing cancer-related lymphedema. In this patients case, cancer-related edema is present despite treatment with a standard lymphedema program. Therefore, Flexitouch pneumatic compression device is likely to be superior over other treatment options. Final Result: The reviewers determined that the requested device 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine 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: A 50-year-old female enrollee has requested authorization and coverage for fiducial markers for treatment of the enrollees malignant neoplasm of unspecified main bronchus.  Findings:  The physician reviewer found that The records provided for review indicate that this patient has a lesion that is in the periphery of the right lung and the provider has recommended placement of fiducial markers. The fiducial marker allows easy identification by imaging or visual inspection ensuring resection of the whole lesion. The fiducial marker is placed during electromagnetic navigation bronchoscopy (EMB). The placement of the fiducial markers is not for diagnosis, but for definitive surgical resection. As there is adequate data demonstrating that this procedure has outstanding outcomes, its use is likely to be more beneficial than standard modalities in this clinical setting. Therefore, the requested fiducial markers placement is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested fiducial markers placement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three 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:  One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ocaliva. Medical guidelines recommend increasing Ocaliva from 5 mg to 10 mg if a patients alkaline phosphatase remains persistently elevated. These findings are consistent in the current peer-reviewed published literature. Further, the U.S. Food and Drug Administration (FDA) prescribing information for Ocaliva does not recommend stopping therapy based on alkaline phosphatase and bilirubin response. In this case, bilirubin is not an accurate metric for response as the patient has Gilberts syndrome. For these reasons, the request for Ocaliva is supported as medically necessary for the treatment of the patients primary biliary cholangitis.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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Grafix skin graft. Findings:  Two of the three medical professional reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. While the literature and studies on Grafix wound dressings are promising, the literature advises that more studies are necessary in order to assess its benefits. This patient has undergone surgical debridement, antibiotics, wound vacuum, and dressings. These treatments have been utilized over many years to treat surgical wounds and infections. The records do not indicate that this patient would not respond to available standard therapy, including the above. Therefore, Grafix skin graft is not likely to be more effective than other treatment options.Final Result: The 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: Medical professional reviewers 1, 2 and 3 are board certified in podiatry 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 cervical/thoracic epidural steroid injection (neck/upper back steroid injection). Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested services. The patients physical examination and MRI demonstrated cervical pathology, and he has received physical therapy and takes a nonsteroidal anti-inflammatory drug. However, the percentage of pain relief and duration of pain relief from prior cervical epidural steroid injections are not clearly documented.  The records do not document that the patient experienced at least 50% relief for four weeks. The evidence supporting the use of cervical epidural steroids is limited, and routine use is not recommended. Therefore, the requested cervical/thoracic epidural steroid injection (neck/upper back steroid injection) 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested reimbursement for FoundationOne testing. Findings:  Three physician reviewers found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells. The hope is that the assay will identify a specific mutation or target which could guide the clinician as to which chemotherapeutic drug would be useful. However, there is a lack of convincing evidence that the assay adds to the decision making ability or yields a result that is reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling, none of which have been convincing as to the efficacy of these analyses. A randomized study by Le Tourneau and colleagues did not demonstrate a significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment. Additionally, finding a mutation does not guarantee that a drug targeting that mutation will produce a clinically meaningful response. Therefore, FoundationOne testing was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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 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: The parent of an enrollee has requested authorization and coverage for autonomic nerve testing. Findings:  Two of the three physician reviewers found this patient has been diagnosed with a mitochondrial cytopathy, and he has multiple symptoms suggestive of dysfunction of his autonomic nervous system. He has chronic constipation, excessive sweating, and wide fluctuations of pulse and blood pressure. Use of autonomic nervous system testing is appropriate when signs or symptoms of autonomic dysfunction are present, a definitive diagnosis cannot be made from clinical examination and routine laboratory testing alone, and diagnosis of the suspected autonomic disorder will lead to a change in management or will eliminate the need for further testing. There is support for the requested services in this patients case. The requested services are likely to be beneficial for this patient, as the records noted a history of two cousins with mitochondrial encephalopathy who have died. Clarification of the patients autonomic dysfunction will permit appropriate clinical management. Thus, autonomic nerve testing is likely to be superior over other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for weekly individual therapy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients behavioral health conditions. The submitted documentation supports the medical necessity of the requested services. Researchers state that psychotherapy is an integral part of patients treatment and should be considered for initial therapy for mild depression and as augmentation to an antidepressant for moderate or severe depression, or for patients with adherence problems. Overall, psychotherapy has been shown to be effective for acute depression, particularly in combination with antidepressants, and it can help in preventing depressive relapse and recurrence. The medical guidelines for the treatment of patients with major depressive disorder notes that depression-focused phototherapy is recommended to prevent a relapse of depression in the continuation phase. Researchers meta-analysis provides evidence that individuals with chronic, complex mental illness seem to improve with long-term psychodynamic psychotherapy and that a greater number of sessions is associated with better outcomes. In this case, psychotherapy has been shown to help reduce this patients symptoms and the patient requires maintenance psychotherapy for the management and treatment of major depressive disorder. The standard of maintenance psychotherapy is weekly, which is both appropriate to treat this patients condition, consistent with good medical practice and medically necessary. Therefore, weekly individual therapy is medically necessary for the treatment of this patient.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the LINX Reflux Management System.  Findings:  Three physician reviewers found there is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX Reflux Management System is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Medical guidelines for the management of reflux disease also state that more evidence is needed before LINX Reflux Management System can be recommended. 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 in this case than standard treatment, surgical fundoplication. For these reasons, LINX Reflux Management System is not likely to be more efficacious than other treatment modalities.Final Result: The 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: Physician reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the gastrointestinal (GI) tract capsule endoscopy. This patient presented with symptoms and visual colonoscopy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and is superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has proven superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. The frequency of small intestinal Crohns disease activity found by capsule endoscopy in a consecutive series was approximately double that detected by computed tomography (CT) enterolysis, leading to changes in the management of a significant number of patients. For these reasons, the GI tract capsule endoscopy was likely to provide useful diagnostic information in this case, and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.One reviewer found that the GI tract capsule endoscopy was not likely to provide useful diagnostic information in this case, and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.Final Result: Two of the 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Mavyret 100-40 mg three tablets daily for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 100-40 mg three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The ENDURANCE-1 trial showed that eight weeks of treatment was effective. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret 100-40 mg, three tablets daily, for eight 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.