Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the molecular pathology testing by Redpath Integrated Pathology, Inc. for evaluation of the enrollees pancreatic cyst. Findings: The physician reviewers found there is sufficient support for the services at issue in this patients case. She had a mucinous pancreatic cyst which puts her at risk for possible malignancy. The standard of care is to test the fluid from the cyst for KRAS and GNAS as part of the diagnostic work-up to guide the need for surgical excision. In sum, molecular pathology testing by Redpath Integrated Pathology, Inc. was likely to be of greater benefit than other modalities for evaluating this patient.Final Result: The 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duexis for treatment of the enrollees rheumatoid arthritis. Findings: The physician reviewer found that the request for Duexis is not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to demonstrate that the patient has tried and failed formulary, generic nonsteroidal anti-inflammatory drugs (NSAIDs) and histamine H2-blockers. Based on the current medical literature, the request for Duexis is not supported as medically necessary. Therefore, the request for Duexis has not been established as medically necessary for treatment of the patients rheumatoid arthritis. 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 rheumatology 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 of Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI). Findings:  The physician reviewer found that there is currently considerable debate about how best to screen for prostate cancer.  The fact that this patients PSA level is stable does not rule out prostate cancer. Prostate cancer is notoriously slow growing, and the lack of progressive elevation does not exclude a malignancy. In general, PSA levels under 4 are not considered abnormal, whereas levels over 4 are regarded as suspicious.  This patient has a PSA level in the 14 to 16 range and his PSA has been persistently elevated. There are many options for therapy (radical prostatectomy, observation and monitoring, brachytherapy, external bean radiation), with no single therapy clearly advantageous, and all therapies having significant risks of complication. Accordingly, MRI has become a common imaging procedure to better evaluate the prostate. The American College of Radiology (ACR) provides recommendations to help guide clinicians as to the most efficient and efficacious means to evaluate various clinical entities. In their publication concerning patients who are clinically suspected with prostate cancer and who has had a prior negative transrectal ultrasonography-guided biopsy, MRI is felt to be the most appropriate study to perform. They found that MRI is a useful adjunct for tumor localization in biopsy negative patients, as in this patients case. A study concurs with the ACR assessment, MRUS fusion biopsy provides improved detection of PCa in men with prior negative biopsies and elevated PSA values. Most cancers found were clinically significant.  This patient fits the ACR criteria and the medical literature. All told, MRI is medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees bilateral knee pain.Findings: The physician reviewer found that the request for Euflexxa injections is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of hyaluronan therapy for treatment of the patients medical condition. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis. The authors found that hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The literature review by Trojian and colleagues recommends hyaluronan acid for appropriate knee osteoarthritis patients. In this case, the patient presents with chronic bilateral knee pain. Clinical examination findings are consistent with reported radiographic evidence of moderate medial compartment and moderate to severe patellofemoral compartment osteoarthritis of both knees. She has failed to adequately improve with anti-inflammatory medications, analgesic medications, physical therapy, and corticosteroid injections. A series of Euflexxa injections have been recommended for both knees as the only option other than knee replacement. She wants to delay total knee replacement given her young age. Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. Therefore, the requested Euflexxa knee injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a prenatal test. Findings:  Three physician reviewers found that the submitted documentation supports the superior efficacy of a portion of the services at issue. The screening with NIPT for the aneuploidies trisomy 13, 18 and 21, which are indicated for advanced maternal age, were supported in this clinical setting due to this patients age. However, the screening for the 22Q11.2 microdeletion involves a rare disorder, and unlike the screening for aneuploidies trisomy 13, 18 and 21, there is a lack current guidelines that would support screening for the 22Q11.2 microdeletion with NIPT. Most of the professional societies recommend against offering microdeletion/duplication syndrome testing as part of routine screening. In sum, the NIPT screening for the aneuploidies trisomy 13, 18 and 21 of the prenatal test performed on 9/15/17 was likely to have been superior over other modalities of evaluating this patient. However, the portion of the test with regards to fetal sex and chromosomal microdeletions was not likely to have been superior to the current standard forms of evaluating this patients medical condition. Final Result: 3 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 physician reviewers are board certified in obstetrics and gynecology 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 Otezla. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  While Otezla is a U.S. Food and Drug Administration approved medication for the treatment of plaque psoriasis, the documentation provided does not indicate that this patient has tried and failed first line therapy with oral systemic agents such as methotrexate, cyclosporine or acitretin, in addition to Enbrel and Humira. He has tried and failed treatment with topical steroids and topical vitamin D analogues. However, there is no medical documentation to support an intolerance or contraindication to the use of methotrexate or acitretin. Therefore, the request for coverage for Otezla should be denied as there are alternative, preferred formulary treatment options available. As there are several other therapies, which are considered first line treatment options, Otezla is 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyaluronan injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that the physician reviewer found the current medical evidence supports the requested services in this patients case. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other nonoperative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Evidence-based, peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allows for delay of total knee replacement. This patient presents with right knee pain with associated giving way and worsening left knee pain, with bilateral loss of range of motion. Clinical examination findings are consistent with x-ray findings of tricompartmental osteoarthritis of both knees. She had failed to improve with recent corticosteroid injections and desires to delay total knee replacement. All told, the requested hyaluronan injections are 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Hysingla ER for treatment of the enrollees pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient has been taking Norco, which is short acting hydrocodone. The request is for Hysingla ER, a long duration form of this same medication. There is no pharmacologic difference in receptor binding. The medication is released slowly. If the patient did not receive adequate relief from Norco, he is unlikely to receive relief from this formulation. Alternative opiates with different receptor binding are available for this patient. The current medical evidence does not support the requested medication in this clinical setting. All told, Hysingla ER 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 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 reimbursement for carotid ultrasound test (carotid duplex scan).  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient had an increased cardiovascular risk but history of carotid disease, no documented symptoms suggestive of neurologic disease, no focal neurologic findings on physical examination and no documented carotid bruits. In this circumstance of no symptoms or findings suspicious for carotid disease, a carotid ultrasound is not considered standard accepted practice in the medical community.  Current guidelines do not recommend screening carotid ultrasound in this setting. Therefore, carotid ultrasound test (carotid duplex scan) was not medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 25 visits of intensive outpatient program (IOP) services provided and forward. Findings:  The physician reviewer found that the 25 visits of IOP services were not and are not medically necessary for the treatment of the patients medical condition. According to the documentation submitted for review, the patient has been documented as making progress with the treatment already provided in IOP. The clinical records submitted for review do not support continuation at the proposed level of intervention. The patient is scheduled to begin a specialized preschool program through his school district  and will receive two 30 minute sessions of speech therapy per week, together with occupational therapy and ABA therapy. These services are medically appropriate to meet the patients medical needs without the implementation of further IOP services.Final Result: The reviewer determined that the services at issue were not and 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 pediatrics and neurology with special qualification in child 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 Mavyret 100-40 mg tablets for eight weeks. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. 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. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Repatha Pushtronix 420 mg/3.5 mL. Findings:  The physician reviewer found that the American College of Cardiology (ACC) has developed an expert consensus decision pathway regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk. This patient is between ages 40 and 75 without atherosclerotic cardiovascular disease (ASCVD) but with diabetes and with LDL cholesterol of 70-189 mg/dL and has an estimated 10-year risk for ASCVD of greater than 7.5%. He is intolerant to statin therapy given his chronic liver disease and also has not been able to tolerate the second-line therapy with Zetia. As this patient was unable to tolerate statin or treatment with Zetia, the requested Repatha Pushtronix 420 mg/3.5 mL is supported as medically necessary for treatment of his medical condition. 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 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.