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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Zoll LifeVest (K0606). The Health Plan has denied this request indicating that the equipment at issue was not medically necessary for treatment of the enrollee who has a history of congestive heart failure. Findings: Current medical literature does not support the equipment at issue in this clinical setting. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed or require explantation. Based on the records provided, the patient had a newly recognized cardiomyopathy with an ejection fraction of 20-25% that subsequently improved on repeat echocardiograms. In this circumstance, there was recovery of left ventricular function over time with medical therapy above the level where a defibrillator is recommended and there was no documented indication for placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. A prophylactic defibrillator, wearable or implantable, during the time period in question has not been demonstrated to improve outcome. Moreover, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. In addition, more recent retrospective trials in patients with newly diagnosed nonischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators.  In addition, preliminary results of the Vest Prevention of Early Sudden Death Trial (NCT01446965) were reported during the American College of Cardiology national meeting and the outcome failed to show a reduction in sudden cardiac death in the group treated with external defibrillators. As such, a Zoll LifeVest (K0606) has not been demonstrated by scientific literature as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the equipment at issue was 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 cardiovascular disease 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 transcranial magnetic stimulation (TMS). TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be well tolerated with fewer barriers than electroconvulsive therapy. The American Psychiatric Association has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. This patient was diagnosed with major depressive disorder by a non-Plan provider . Per the submitted documentation, the diagnosis of major depressive disorder is established. Based on the relevant medical records, coupled with the expanding peer-reviewed literature base, TMS represents a safe and appropriate treatment intervention for this case. The requested services are consistent with good medical practice and are reasonably expected to both improve the patients condition and prevent a more serious episode of illness. All told, TMS 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A enrollee has requested authorization and coverage for Dupixent. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication. The patient has requested coverage for Dupixent for the treatment of severe atopic dermatitis. Per the records, the patient has been treated with topical steroids, calcineurin inhibitors, and oral antihistamines, without relief. The Health Plan is requiring the treatment with phototherapy (UVB or PUVA), or systemic treatment (for example, corticosteroid or immunosuppressants). It is reasonable to require that the patient trail and fails therapy with ultraviolet light or systemic immunosuppressants prior to approving Dupixent. The medical evidence does not support the requested medication in this clinical setting. Therefore, Dupixent is not medically necessary for the treatment of this patient.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 dermatology 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 genetic testing. The National Comprehensive Cancer Network (NCCN) testing guidelines recommend BRCA testing for this patient, since she has a first or second degree relative with breast cancer under the age of 45. However, what is being requested is the MyRisk panel that includes BRCA within it but also a variety of other suspected risk genes. Though many of these other gene mutations are of interest, there is a lack of data demonstrating that these findings are significant to be support a basis for clinical decision making. Such broad testing is not included in the guidelines from the major organizations such as American Society of Clinical Oncology (ASCO). Therefore, BRCA but not the remainder of the myRisk panel testing would be of possible clinical benefit to this patient. Thus, the BRCA1 and BRCA2 portions of the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the genetic testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that a portion of the genetic testing performed 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:  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for treatment at a tertiary level facility. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients malignant neoplasm of the left breast. The submitted documentation does not support the medical necessity of the requested services. Breast cancer is the most common type of cancer in women. Treatment algorithms are standard across institutions, unless patients are enrolled in a clinical trial. There is a clear standard of care for the adjuvant treatment of breast cancer, The records do not document that this patient has plans to participate in a clinical trial. Therefore, the patient would receive similar care wherever the patient is treated. There are medical oncologists available within her network. Therefore, treatment at a tertiary level facility 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 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orgain Kids nutritional shakes. The Health Plan has denied this request indicating that the requested oral formula is not medically necessary for treatment of the enrollee who has a history of diffuse leukomalacia.Findings: The submitted documentation does not support the medical necessity of the requested oral formula. The patients symptoms of gagging and vomiting are multifactorial. Contributors to these symptoms include aspiration, constipation, baclofen use, and episodes of dysmotility, in addition to a possible sensitivity to PediaSure.  The parents have requested an organic nutritional shakes. The records do not indicate that this patient has tried a conventional soy free formula. Additionally, the medical literature is unclear as to the affect organic food has on human health. Overall, there are limited studies on the risk of nausea with organic versus conventional formulas. In addition, there is a lack of medical evidence to support that the Orgain Kids nutritional shake has a beneficial health effect for all conditions. For these reasons, the medical necessity for Orgain Kids nutritional shakes have not been demonstrated for the treatment of this patients medical condition.Final Result: The reviewer determined that the requested oral formula 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 pediatric gastroenterology with expertise in pediatric nutrition 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 reimbursement for anesthesia services rendered during a colonoscopy procedure. The Health Plan has denied this request indicating that the services at issue were not medically necessary for management of the enrollees during a colonoscopy procedure. Findings: According to the ASA guideline for anesthesia care during endoscopic procedures, MAC is warranted in prolonged or painful procedures such as complex polyp resections, endoscopic retrograde cholangiopancreatography or other biliary procedures, endoscopic dilation, or endoscopic resection. Additionally, the guidelines state that MAC may be appropriate for patients with failed history of moderate sedation for the procedure or psychological impediments to cooperation. In this patients case, the provided records do not support any of these criteria. Moreover, the other criteria mentioned in the literature such as difficult intubation, airway obstruction, allergies to sedation medications, chronic alcohol or illicit drug use resulting in increased tolerance to sedation medications, age greater than 70, pregnancy, increased aspiration risk, ASA Class III or higher, or morbid obesity have not been met. According to the recent guidelines from the American Society for Gastrointestinal Endoscopy (ASGE), during endoscopic procedures, unlike surgery, consciousness during the procedure is acceptable and is the goal during most procedures, which are performed with moderate sedation. MAC is recommended for prolonged procedures requiring deep sedation, previously anticipated intolerance to standard sedatives, ASA Class IV or V, or risk for airway obstruction due to anatomic variant. For these reasons, the provided patient records do not support the medical necessity of the MAC services rendered during a colonoscopy procedure. Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy. Therefore, the Health Plans denial should be upheld.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: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus, genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a patients should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg tablets for eight weeks 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for cryoablation of left occipital nerve. As noted in the medical literature, occipital nerve blocks are not supported for the treatment of migraine or other type headaches. Occipital nerve blocks are supported for diagnostic purposes but are not supported for therapeutic treatment as there is a lack of long-term benefit supported by the current peer-reviewed medical literature. A report noted there was no long-term improvement of chronic migraine type headaches with use of occipital nerve block. Another report reported that greater occipital nerve blocks do not reduce the frequency of moderate-to-severe migraine days in patients with episodic or chronic migraine compared to placebo. There was no long-term improvement of headache of chronic migraine type with use of occipital nerve block. For these reasons, the medical records do not indicate that cryoablation of the left occipital nerve is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that cryoablation of the left occipital nerve is 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 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:  One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in neurology and is actively practicing.  One Reviewer is board certified in neurology 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 suction assisted lipectomy. The submitted documentation supports the medical necessity of the requested services. The records document evidence of lipedema of the lower extremities complicated by secondary lymphedema. She is well-documented to have undergone extensive conservative management. Her lipedema has been noted to have adversely affected her function, with chronic pain. Photographs support the abnormal lower extremity enlargement consistent with her diagnosis. Liposuction is a well-known therapy for lipodystrophy and has been shown to provide functional improvement in lipedema. The medical evidence supports the requested services in this clinical setting. Therefore, suction assisted lipectomy is medically necessary for the treatment of this patient. Additionally, the patients condition constitutes an abnormal structure of the body. Lipedema is an abnormal distribution of fat and is a well-recognized disorder. Lipedema is classified as a disease. The requested services are likely to both improve function and create a normal appearance to the extent possible. The requested suction assisted lipectomy is likely to result in more than a minimal improvement in the appearance of the patient. Thus, the requested suction assisted lipectomy is reconstructive in nature. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be 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. Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.Findings: According to the 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 virus should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. 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, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage and recommend 12 weeks of Zepatier when NS5A resistance testing is not available, as in this patients case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and the request for Zepatier 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.