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 Optune treatment and prospective authorization and coverage for future Optune treatment for treatment of the enrollees glioblastoma.  Findings:  The 3 physician reviewers found that the physician reviewer found Optune is a novel portable medical device that generates low intensity alternating electric fields. This treatment has been approved by the U.S. Food and Drug Administration for the treatment of glioblastoma. It is a helmet-like device that is attached to the scalp, and continuous treatment is recommended. This approval was based on a single controlled trial by colleagues of patients. The authors found that patients treated with the device had the same overall survival with residual glioblastoma as did those treated with chemotherapy, but with a much better toxicity profile. In this difficult to treat malignancy, there is sufficient data to support the use of Optune therapy. Therefore, Optune treatment was and is likely to be more effective than other treatment options. Final Result: The 3 reviewers determined that the services at issue were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Danmar soft shell helmet for treatment of the enrollees seizure disorder. Findings:  The physician reviewer found that the submitted documentation as well as the medical literature provide support for the requested equipment in this patients case. There is medical literature that documents the association between seizures and head injuries. Head trauma is a common occurrence in patients with intractable epilepsy.  The ramifications of this event can be reduced through the use of a helmet.  In this case, compliance and use of a standard bike helmet would be limited given the patients baseline strength. In the past, the patient has tolerated a Danmar helmet well with reported reduction of head traumas during seizures. To this end, it is reasonable for this patient to continue to use this type of helmet. The patient requires protection from potential risk of head trauma when her seizures occur. For these reasons, Danmar soft shell helmet is medically necessary for this patient. Final Result: The reviewer determined that the requested equipment 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 reimbursement for fertility preservation services (fertility testing, chemistry procedures, diagnostic ultrasound, measurement of human chorionic gonadotropin (HCG), gonadotropin-follicle stimulating hormone (FSH), oocyte retrieval, cryopreservation of oocytes) for treatment of the enrollee who has a history of breast cancer. Findings:  The physician reviewer found that there is support in the medical literature for the services at issue. With current technology, sperm and embryo as well as oocyte cryopreservation, are considered standard practice and are widely available. In this case, the patients fertility status after breast cancer treatment was uncertain. The submitted documentation indicates that the plan for this patient would be to undergo fertility treatment as soon as the cancer diagnosis was confirmed and prior to the initiation of the chemotherapy. Although there was no specific treatment plan, treatment options were considered that included chemotherapy. Because of the unpredictable nature of a cancer diagnosis and future treatments, the American Society of Clinical Oncology and the American Society for Reproductive Medicine guidelines recommend immediate fertility treatment so that the opportunity is not lost and cancer treatment is not delayed. Such treatment is considered the standard of care by these societies. Additionally, the current evidence appears to indicate that these fertility treatments have been shown to be successful.  Therefore, in order to preserve this patients fertility, it was medically necessary for this patient to undergo fertility sparing treatment.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for follow-up eye surgery. Findings:  The physician reviewer found that, according to the medical records provided for review, the patient has had treatment for complicated retinal detachment. Although the patient has recovered from the surgery, her provider noted that she has poor prognosis for additional improvement with further surgery. The evaluation demonstrated that the right eye condition is stable. Thus, the requested follow-up eye surgery is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 ophthalmology 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: The patient has requested reimbursement for neurofeedback for treatment of the enrollees behavioral health issues. Findings:  Three physician reviewers found that there are limited studies regarding the efficacy of neurofeedback in the treatment of anxiety, insomnia, and attention deficit hyperactivity disorder (ADHD). Researchers found no difference between neurofeedback and placebo in subjective measures of sleep complaints. The authors concluded that based on this comprehensive and well-controlled study, we conclude that for the treatment of primary insomnia, neurofeedback does not have a specific efficacy beyond unspecific placebo effects. Importantly, we do not find an advantage of neurofeedback over placebo feedback, therefore it cannot be recommended as an alternative to cognitive behavioral therapy for insomnia, the current (non-pharmacological) standard-of-care treatment. Cognitive behavioral therapy (CBT) for insomnia is considered the gold standard non-pharmacological treatment. Overall, the records do not document that this patient participated in this non-pharmacological treatment or that he has exhausted standard medical therapies. Final Result: The reviewers determined that the services at issue were 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: Reviewers 1, 2 and 3 are board certified in psychiatry and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that The physician reviewer found 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 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. All told, Mavyret 100-40 mg is medically necessary for the treatment of this patient. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for 35 additional days of residential therapy treatment services for treatment of the enrollees obsessive compulsive disorder (OCD), major depressive disorder, recurrent, severe, without psychotic features, and attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that In accordance with modern psychiatric practice, the records document that this patient has pursued treatments in less restrictive treatment settings other than residential level of care. She began with outpatient services and was stepped up to PHP. Despite the higher level of care and complex pharmacotherapy, the patient remained symptomatic with an illness burden that was negatively impacting all functional domains. Thus, her providers recommended residential placement. Such progression in level of care is consistent with the recommendations from the American Psychiatric Association (APA). The APA noted that, residential treatment may be indicated in individuals with severe treatment-resistant OCD, who require multidisciplinary treatment in a highly structured setting that permits intensive individual and group CBT [cognitive behavioral therapy] as well as psychopharmacologic management with close monitoring of treatment adherence over a period of several months. In sum, the patient has a history of mental illness dating back to childhood. She has multiple psychiatric diagnoses and a formidable symptom complex that has included suicidal behavior. She has failed less restrictive treatment settings during the episode of illness. She is motivated for recovery and is actively engaged in evidence based treatment. The setting and services in dispute are consistent with contemporary psychiatric practice, and are reasonably expected to both improve her condition and prevent a more serious episode of illness. However, based on the clinical documentation, the specific request for 35 days of additional treatment is not supported as medically necessary. Typically, an initial 30-day residential admission would be consistent with community standards in a case such as this. For these reasons, residential therapy treatment services are medically necessary through 12/15/17 for treatment of the patients medical condition, but not thereafter. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. In an undated letter, a provider reported that biologics have been avoided due to their immunosuppressive properties, side effects and previous treatment failures. This patient has tried and failed therapy with Humira and this patients treating provider does not recommend treatment with additional immunosuppressive agents.  Otezla is a U.S. Food and Drug Administration (FDA) approved oral agent for the treatment of psoriasis and psoriatic arthritis. Its safety profile does not require any routine blood monitoring for systemic side effects. The patient has tried and failed therapy with an injectable systemic biologic agent and has failed treatment with immunosuppressive therapies. Therefore, Otezla is medically necessary for the 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 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 Vemlidy for treatment of the enrollees 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 entecavir and tenofovir compared with alternatives for the treatment of chronic Hepatitis B. In comparison with tenofovir disoproxil fumarate (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. Viread and Vemlidy are both effective for the treatment of hepatitis B, however the Vemlidy form is safer for long-term use. For this reason, the request for Vemlidy is medically necessary for the treatment of the patients chronic hepatitis B. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that There is a lack of a support for the medical necessity of the services at issue in this clinical setting. The patient was admitted to the residential treatment center services with a weight of 129 pounds. The record noted that her ideal body weight (IBW) was 112.5 pounds, so her admission weight was 114% of her IBW. The patient has chronic suicidal ideation and has a history of seven suicide attempts. Her last self-injury was in April 2017. The patient had passive suicidal ideation with no intent or plan. She was medically stable and did not require 24 hour observation. The records do not indicate that the patient was medically compromised. The medical evidence indicates that inpatient treatment does not provide advantages over outpatient management. It is the standard of care to treat patients in the least restrictive environment possible. The patient had an IBW of 114% and could have been treated at a lower level of care, such as a partial hospitalization program. Therefore, RTC services were not medically necessary for the treatment of this patients medical condition.  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 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 neratinib 240 mg (six 40 mg pills) by mouth, daily for one year for treatment of the enrollee who has a history of stage III left breast cancer. Findings:  The physician reviewer found that there is support for the requested medication in this clinical setting. Per the National Comprehensive Cancer Network (NCCN) guidelines, neratinib may be considered as extended adjuvant therapy following adjuvant trastuzumab containing therapy in HER2 positive patients with a perceived high risk of recurrence such as stage II-III. This patient fits the criteria recommended by NCCN guidelines. Additionally, in a study by colleagues, they found that neratinib significantly improved two year invasive disease free survival when given after chemotherapy and trastuzumab based adjuvant therapy to patients with HER2 positive breast cancer. Moreover, the package insert states that neratinib is indicated for the extended adjuvant treatment of adult patients with early stage HER2 disease to follow adjuvant Herceptin based therapy. For the reasons mentioned above, the requested neratinib 240 mg (six 40 mg pills) by mouth, daily for one year is medically necessary for the treatment of this 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for hyaluronan (Orthovisc) injections in the left knee for treatment of the enrollees knee pain. Findings: The physician reviewer found that 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. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors 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. In this case, it is documented the patient has been treated with physical therapy, braces, Norco, and underwent corticosteroid injections. Moreover, the patient is not a reasonable candidate for repeat corticosteroid injections so close to the time of planned revision right knee arthroplasty which might increase risk of periprosthetic joint infection. Previously, the patient has experienced success with viscosupplementation. For these reasons, the requested hyaluronan (Orthovisc) injections in the left knee is supported as medically necessary for treatment of this 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.