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

Nature of Statutory Criteria/Case Summary: A 62-year-old female enrollee has requested reimbursement and prospective authorization and coverage for Monovisc hyaluronan injections to the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A study conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. A study reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. Given this support, the Monovisc hyaluronan injections to the right knee were and are medically necessary for treatment of this patients advanced osteoarthritis. Final Result: The reviewer determined that the services at issue were and 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 reimbursement for transcranial magnetic stimulation therapy (TMS). TMS is a non-invasive, neurostimulatory intervention endorsed by the American Psychiatric Association for the treatment of acute phase depression in the adult population. TMS does not have an indication for anxiety or chronic depression at this time. A study found the standard parameter set provided clinical benefit in treatment courses up to six weeks in duration. Controlled studies of longer duration, acute treatment courses or using alternative treatment parameters are not established. The Clinical TMS Society recommends considering continuation or maintenance TMS therapy when other established methods of maintenance antidepressant therapy fail to provide a satisfactory sustained pattern of clinical benefit or a patient has a history of frequent relapse. However, according to the medical records, the patient was still symptomatic and far from remission with ongoing TMS therapy while the documentation did not establish the failure of standard interventions. Additionally, despite the severity of her illness burden, there was no mention of consideration for intermediate treatment settings, such as intensive outpatient services, partial hospitalization programming or residential placement. Finally, there was no discussion of the previous ECT trial, aside from its lack of efficacy. As ECT remains the proven non-pharmacologic intervention in the treatment of depression to which other stimulatory techniques are measured, a critical review of the prior course of treatment, and possible reconsideration of the modality, may have been appropriate.  In sum, TMS was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the patient-activated cardiac recorder implant and monthly event recordings of the device. This patient underwent evaluation with prolonged cardiac monitoring using an implantable cardiac monitor to delineate an etiology for her near syncopal episodes. Transient arrhythmias such as supraventricular tachycardia or bradyarrhythmias could potentially affect therapeutic strategies. Despite the fact that the patient underwent previous radiofrequency ablation of her supraventricular tachycardia, recurrence of this arrhythmia could be responsible for her intermittent symptoms. Reliance on the nature of her symptoms could not differentiate a sinus tachycardia from a reentrant tachyarrhythmia. Further, the patient reportedly could not tolerate the adhesive patches required for routine ambulatory monitoring. Documentation of the precise rhythm disturbance is critical in directing this patients management. An implantable loop monitor with possibly prolonged surveillance was appropriate to arrive at an accurate diagnosis. Therefore, the patient-activated cardiac recorder implant and monthly event recordings of the device were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the patient-activated cardiac recorder implant and monthly event recordings of the device were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the patient-activated cardiac recorder implant and monthly event recordings of the device were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: A patient has requested authorization and coverage for robotic-assisted total laparoscopic hysterectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the patients endometriosis and uterine fibroids. The submitted documentation of the patients medical needs does not support the medical necessity of the requested services. The patient does have a well-established history of pelvic pain. However, the patient has never been treated with medical or conservative surgical management. The patient has not had a diagnostic laparoscopy and does not have a tissue diagnosis of endometriosis. The patients ultrasound shows a fairly normal sized uterus and it does not show large or rapidly growing fibroids, when compared to the ultrasound in 2012. Under these circumstances, it is reasonable to trial conservative medical and/or surgical management prior to proceeding with a hysterectomy. Therefore, a robotic-assisted total laparoscopic hysterectomy is 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 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 the genetic testing (molecular profiling). There is a paucity of prospective randomized controlled studies demonstrating improved outcomes utilizing results obtained from expanded genetic panel tests. The American Society of Clinical Oncology (ASCO) guidelines continue to encourage research to delineate the optimal use of panel-based testing, development of evidence-based practice guidelines as data emerges, and education of providers regarding challenges in the use of these tests. However, based on the current peer-reviewed medical literature, genetic testing has not been correlated with improved outcomes in this clinical setting. All told, the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the genetic testing (molecular profiling) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested reimbursement for the acute rehabilitation services. The Health Plan has denied this request indicating that the requested services were not medically necessary for treatment of the patients stroke. The submitted documentation does not support the medical necessity of the services at issue. In this patients case, the clinical record does not support justification of additional acute inpatient rehabilitation services beyond the physicians and interdisciplinary teams recommendations for discharge to home with assistance. The required family education and training was completed in preparation for the patients discharge. The physicians and interdisciplinary teams recommendations for discharge were based on objective review of the patient's progress toward rehabilitation goals, prognosis stroke recovery, and recommended discharge disposition to home. Therefore, acute rehabilitation services were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is a nonsmoker who was diagnosed with a metastatic non-small cell adenocarcinoma of the lung that was found to be epidermal growth factor receptor (EGFR) mutation positive. The patient received treatment with afatinib and Xgeva. The patient has requested reimbursement for FoundationOne blood test performed. The Health Plan has denied this request as investigational. Findings: The services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Although this patient has already had molecular profiling with Guardant360, she has become resistant to EGFR based therapy with afatinib. In addition, Guardant360 is a liquid biopsy evaluated from a sample of the patients blood and not considered as accurate as FoundationOne. Molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. Medical guidelines strongly advises broader molecular profiling with the goal of identifying rare driver mutations, for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Prior molecular profiling, such as with FoundationOne, was not done on this patients lung tumor. Therefore, the FoundationOne blood test performed 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 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 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: A male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. On admission to RTC level of care, the patients withdrawal symptoms were described as mild-to-moderate. He was not a danger to himself or others. He has been able to care for himself. There have been no emotional, behavioral, or cognitive factors prevent him from receiving treatment at a lower level of care. The patient has not reportedly received substance abuse treatment at a lower level of care. Although HIV positive, his viral load was undetectable, and he has been otherwise medically stable. His vital signs have been stable. He has been psychiatrically stable as well, in the sense that his medication management has not required the residential setting for the minimal changes that have been made. He has not demonstrated aberrant behavior, he has not been manic, psychotic, or agitated. He has a supportive family. There have been no barriers to being effectively treated at intensive outpatient program (IOP) level of care. All told, the patient did not and does not require the strict and restrictive setting of 24-hour monitoring at residential level of care. Accordingly, the RTC services provided were not and are not medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with sub-specialty certification in addiction 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 Repatha Sureclick (evolocumab subcutaneous solution auto-injector 140 mg/mL). Based on the records provided, the patient has documented obstructive coronary disease and hyperlipidemia with an LDL above a goal of less than 70 mg/dL while on maximally tolerated statin medication. In this clinical setting, the addition of Zetia has been shown to be safe and effective at further lowering LDL cholesterol and has been associated with improved health outcomes. In addition, Zetia is recommended due to a favorable side effect profile compared to proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors. Moreover, Zetia is preferred due to ease of administration in oral pill form as opposed to subcutaneous injection. Therefore, the documentation does not support the medical necessity of Repatha Sureclick (evolocumab subcutaneous solution auto-injector 140 mg/mL) for 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 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

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 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, 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.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets daily, 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: Upheld Decision of Health Plan

The parent of an enrollee has requested authorization and coverage for Norditropin FlexPro. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The patients height is not more than two standard deviations below the mean for age and gender. His insulin-like growth factor 1 (IGF-1) level was normal, and his bone age was normal. He does not have known morphologic abnormalities of his pituitary gland. Although he is relatively short in comparison to his family, he does not meet criteria for growth hormone deficiency. His slight fall-off in growth between 10 and 12 years of age occurred simultaneous with weight fall-off and is not typical of growth hormone deficiency. Therefore, Norditropin FlexPro is not medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 40-year-old female 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. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret 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 (case study). The ENDURANCE-1 trial showed that only eight weeks of treatment is needed (case study). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (case study). For these reasons, the requested Mavyret 100-40 mg, three tablets daily, for eight weeks is supported as medically necessary for treatment of this patients hepatitis C virus 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene mutation blood test. Findings:  Three physician reviewers found that the evidence suggests that the MTHFR genotype plays a minor and negligible role in predicting risk of thrombosis. There is a lack of evidence supporting the utility of screening for MTHFR mutations in the management of patients, or family members of patients, with a history of thrombosis. The medical evidence does not support the services at issue in this patients case. In sum, the superior effectiveness of gene mutation blood test has not been established.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 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.