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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that There is a lack of support in the literature for the use of Xeljanz (tofacitinib) in the treatment of rheumatoid arthritis (RA). The 2015 American College of Rheumatology (ACR) guideline, for the treatment of rheumatoid arthritis recommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  The guidelines noted, there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib.  A second TNFi with or without  MTX of non-TNF biologic with or without  agent is recommended over Xeljanz. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA.  There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi.  Smolen and colleagues noted the following, Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors.  There are currently no studies looking at failure of first TNFi agent and a different biologic agent.  In this case, the patient has failed methotrexate, hydroxychloroquine, sulfasalazine, leflunomide.  However, it is unclear if the patient did not respond to the first TNFi (Humira) as this was stopped due to frequent urinary tract infections and a skin reaction attributed to possible latex allergy while taking Humira. Additionally, the patient has not failed a second TNFi or a non-TNF biologic agent as recommended in the 2015 ACR guidelines. The records fail to demonstrate any contraindications to a trial of a second TNFi.  As such, the request for Xeljanz is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that that 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

`Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis on both sides at facets L3 to S1 for treatment of the enrollees low back pain. The submitted documentation does not establish the superior efficacy of the requested services. Repeated radiofrequency ablation for lumbar facet syndrome may provide pain relief.  The medical evidence indicates that radiofrequency ablation may be successful in treating lumbar spine pain in a repeated fashion in selected patients. In this patients case, he has received radiofrequency ablation in the past. Based on the documentation, his most recent radiofrequency ablation was performed several years ago. This treatment was performed at L4-S1. Radiofrequency ablation can be repeated with success. However, when the previous radiofrequency ablation was greater than one year prior, confirmation injections are needed. In this case, the records do not document that confirmation testing was performed. Therefore, radiofrequency neurolysis on both sides at facets L3 to S1 is not likely to be more efficacious than other available treatment modalities. Final Result: Two of the three 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hyperbaric oxygen therapy for treatment of the enrollee, who has a chronic non-healing wound.Findings:  The physician reviewer found that this patient has a chronic non-healing diabetic foot ulcer with complicating refractory osteomyelitis. The wound is classified as a Wagner stage 3 diabetic ulcer. The patient has been advised to proceed to the hospital for admission and amputation by his provider, but he has declined this treatment. His treatment has included local wound care, total contact cast, ongoing empiric antibiotics and at least 60 sessions of hyperbaric oxygen therapy. Hyperbaric oxygen therapy may be associated with improved healing as a component of diabetic ulcer management, but the indications for hyperbaric oxygen in the treatment of non-healing diabetic foot ulcers remain uncertain. The cornerstone of diabetic foot wound care includes adequate debridement, proper local wound care (debridement and dressings), redistribution of pressure on the ulcer by mechanical offloading, and control of infection and ischemia, regardless of stage and depth. There is a lack of randomized clinical trials evaluating the effects of hyperbaric oxygen on chronic, refractory osteomyelitis. This patient continues to have underlying infection that has been refractory to treatment. There has not been significant wound healing despite the previous 60 sessions of hyperbaric oxygen. There is a lack of support for the requested services in this clinical setting. All told, the requested hyperbaric oxygen therapy 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 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 reimbursement for inpatient behavioral health level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The progress notes from the disputed period indicate that the patient had initially improved, and catatonic symptoms were not present.  However, after several days, the patients catatonic symptoms returned.  He was not able to take care of his activities of daily living and was also not eating. During the timeframe when the patient was again catatonic, it does not appear that he could have been treated on an outpatient basis or in a partial hospital program due to his symptoms as well as noted suicidal ideation.  During the last two days of the stay, it appears that he again improved. However, the patient also showed similar improvement during the middle of his status. It appeared reasonable that the patient would need to stay in hospital for the last several days of the disputed period due to the fact that he had decompensated after an initial period of improvement earlier during his stay. The current medical evidence supports the services at issue in this clinical setting. All told, inpatient behavioral health level of care services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:e enrollee has requested authorization and coverage for rituximab injection 100 mg for treatment of the enrollees autonomic neuropathy associated with anti-acetylcholine receptor antibody with gastric dysmotility. Findings:  The physician reviewer found that Dysmotility disorders can be caused by multiple causes. In this case, the patients dysmotility is caused by anti-acetylcholine receptor antibody. In such cases the use of an autoimmune treatment is supported as beneficial in the medical literature. In anti-Hu paraneoplastic syndromes, therapy of the underlying tumour remains the mainstay. Where there is no tumour found, immunologically based therapies such as rituximab can be effective in anti-Hu paraneoplastic syndrome with gastrointestinal dysmotility. As such, the patient is likely to benefit from the proposed therapy. Therefore, the request for rituximab injection 100 mg has been established as medically necessary for treatment of the patients 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma assay testing for evaluation of the enrollees cutaneous melanoma. Findings:  The physician reviewers found that in thick melanoma tumors, like in this patients case, the standard of care is to do a wide local excision with possible sentinel lymph node dissection and base any further treatment on these results. Options for adjuvant treatment include immunotherapy, targeted therapy, BRAF and MEK inhibitors and chemotherapy. The standard protocol, based on National Comprehensive Cancer Network (NCCN) guidelines for a thick tumor, does not include a workup with molecular testing. Currently, the testing has shown some impressive results in predicting risk of metastasis. However, there is no set change in treatment protocol based on the findings. The standard protocol would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. Clinical studies which show that the results of the molecular testing will make a difference in the treatment or morbidity/mortality are lacking at this time. It is for this reason that the DecisionDx-Melanoma testing is considered experimental or investigational for patients with thick melanoma tumors. Since this test does not provide a benefit more than the established tests as to outcomes and treatment options, the DecisionDx-Melanoma assay provided was not likely to have been more effective in the evaluation of this patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in dermatology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Divigel 1 mg/gram (0.1%) gel packet for treatment of the enrollees menopausal symptoms.  Findings:  The physician reviewer found that according to a study, Once a decision has been made to treat a postmenopausal woman with estrogen, consideration should be given to the type of estrogen and the route by which it is to be given, as well as the need for progestin and the most appropriate progestin regimen. Estrogen is available in many forms: oral, transdermal, topical gels and lotions. The potency and therefore the doses of these estrogen preparations differ, but they differ little in efficacy. The documentation provided for review does not show that the patient has tried any of the Health Plans formulary alternatives. In addition, various patches may use different adhesives, so one might be tolerated when another was not. An oral option eliminate the possibility of skin reactions. 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 obstetrics and gynecology 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 coronary computed tomography angiography (CCTA) for evaluation of the enrollee, who has aortic valve stenosis.Findings:  The two of the physician reviewers found that This patient had increased coronary risk and severe asymptomatic aortic valve stenosis with normal left ventricular systolic function. In this circumstance of no documented cardiac symptoms and normal left ventricular function, there is no accepted indication for aortic valve replacement according to current guidelines endorsed by several national organizations. Therefore, coronary angiography was not indicated. Moreover, if coronary angiography were thought to be indicated, then conventional coronary angiography would be preferred, given its improved accuracy relative to CCTA and the ability to intervene with coronary revascularization during the same procedure, if clinically indicated. In sum, CCTA was not likely to have been of greater benefit 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: The enrollee has requested authorization and coverage for breech delivery for treatment of the enrollees fetus in breech presentation.  Findings:  The physician reviewer found that the request for breech delivery is medically necessary for treatment of the patients medical condition. The American College of Obstetricians and Gynecologists Committee Opinion noted that, The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery; Obstetricians should offer and perform external cephalic version whenever possible; Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management; In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented; and Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned. Based on the documentation provided for review, the patient should have the opportunity to have an external cephalic version (ECV) and/or breech vaginal delivery given that records do not demonstrate a contraindication for breech vaginal delivery. For the reasons provided, the requested service is 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. FCredentials/Qualifications: The reviewer is board certified in obstetrics and gynecology 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 enrollee has requested authorization and coverage for H.P. Acthar Gel for treatment of the enrollees multiple sclerosis (MS).  Findings:  The physician reviewer found that H.P. Acthar Gel is U.S. Food and Drug Administration (FDA) approved for the treatment of MS relapses. The patient had previously tried IV steroids on two separate occasions for relapses with minimal efficacy. The patient was treated with H.P. Acthar Gel and had a good response. Given the patients poor response to IV steroids, and improved response to H.P. Acthar Gel, the requested medication has been established as medically necessary for treatment of the patients MS. 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 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 Vemlidy for treatment of the enrollees chronic hepatitis B virus.Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend Baraclude and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. 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 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.