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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Assay. Findings:  Three physician reviewers found that the DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Assay test has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was 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: All three physician reviewers are board certified in dermatology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for consolidation therapy (durvalumab) every two weeks for one year for treatment of the enrollees squamous cell carcinoma of lung. Findings:  Three physician reviewers found that durvalumab is one of a newer class of drugs, programmed death-ligand 1 (PDL-1) inhibitors. It was approved for use in metastatic urothelial carcinoma. However, a recent randomized study strongly suggested its efficacy as therapy post chemotherapy in non-small cell lung cancer. In that study of approximately 700 patients, all of whom had non-small cell lung cancer, had received chemotherapy, and their disease had not progressed. The participants were randomized to either have consolidation durvalumab or placebo. The median progression free survival of patients on durvalumab was 16.8 months, versus 5.6 months on placebo. At 18 months, 72.8% of patients on durvalumab had not progressed, versus 46.8 % on placebo. The development of distant metastases was 23 months on durvalumab versus 15 months on placebo. The conclusion was that the use of durvalumab in this situation was of significant clinical benefit. This use of durvalumab has been adopted by the National Comprehensive Cancer Network guidelines. As such, the medical evidence demonstrates a clinical benefit in patients who are treated with durvalumab as maintenance therapy. For these reasons, consolidation therapy (durvalumab) every two weeks for one year is likely to be more efficacious than the available standard therapy for the treatment of this patients medical condition.Final Result: The reviewers determined that the requested medication is 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 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 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable first-line therapy, and neither has proven to be safer or more effective than the other in a direct comparison trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 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 patients parent has requested authorization and coverage for Adzenys XR-ODT. Findings:  The physician reviewer found that although Adzenys XR-ODT has not been demonstrated to be more effective than Adderall XR, this patients records document that Adzenys XR-ODT provides a better method of administering the medication that the patient can tolerate. The patients parent states that attempts to open the Adderall XR medication and sprinkle the Adderall XR contents in water or food was unsuccessful and that the patient was unable to tolerate this. The patient has attempted many alternative ways to administer the ADHD methods through capsules, sprinkles, tablets, and liquid form, but the patient has not been able to tolerate any of these administration methods. It does appear that the oral dissolvable tablets would benefit the patient as he has failed all other methods to properly ingest his ADHD medication. Therefore, the requested Adzenys XR-ODT is medically necessary for 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 psychiatry with expertise in child and adolescent 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: The parent of an enrollee has requested authorization and coverage for Lyrica for treatment of the enrollees chronic daily headache, generalized anxiety disorder, and major depression. Findings: The physician reviewer found that based on the medical records, the patient has a history of debilitating migraine headaches which has significantly impacted his ability to go to school. This in turn is likely to contribute to loss of self-esteem, increased anxiety and other emotional stress, all of which could contribute to his depression. Lyrica has been demonstrated to have significant efficacy compared to the historic benchmark agent, propranolol which parenthetically is contraindicated in this patient because of its potential to cause depression in reducing headache frequency. Therefore, using Lyrica makes good therapeutic sense for this patients pharmacotherapeutic regimen, particularly with respect to his headaches. Accordingly, the requested Lyrica is supported as medically necessary for 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne testing provided for evaluation of the enrollees non-small cell lung cancer.Findings: Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) NSCLC guidelines strongly advise 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. Therefore, the FoundationOne testing provided was likely to be more beneficial for evaluation than available standard therapy to guide decision making.Final Result: The reviewers determined that the testing 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services, partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that According to the documentation submitted for review, the patient showed post-acute withdrawal symptoms which were at best moderate.  The patient was medically stable.  There were no emotional or behavioral factors present, however the patient had cognitive impairment manifested by short term memory difficulties. The patient was uncertain of the date and was unable to perform serial additions. The patients past history suggests a high probability of impulsivity if discharged.  The patient was not manic or psychotic, nor a danger to self or others. The patient has been in multiple detoxes and other treatments, as well as 12 steps with a sponsor, still showing an inability to remain sober beyond 14 months, and relapsing while on Suboxone maintenance. The patient was compliant and engaged in treatment but showed no indication of having coping skills. Thus,  the patient was able to recognize triggers towards relapse, and could have been stepped down to an ambulatory level of care, while remaining on medication assisted treatment (Suboxone), which is typically done on an outpatient basis. The patients appetite, sleep, and post-acute withdrawal symptoms improved. The patients vital signs were stable. The patient became internally motivated and was highly engaged. There were no medication changes other than adding Paxil and naloxone spray. The patient could have been treated at IOP level of care, then moved to an outpatient level of care. Both IOP and outpatient levels of care could have been supplemented with community supports of 12 step programs, counselors, sponsors, outpatient therapists, and reaching out to sober support systems. For the reasons provided, the residential treatment center services provided were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue was 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 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: The parent of an enrollee has requested authorization and coverage for Genotropin for treatment of the enrollees Prader-Willi syndrome. Findings:  The physician reviewer found that the request for Genotropin is not medically necessary for treatment of the patients medical condition. GH treatment for children with Prader-Willi syndrome has been shown to improve linear growth and promote growth of lean body mass, decreases fat mass by increasing fat oxidation and total body energy expenditure, and improves cardiovascular risk factors. Complications of GH therapy in children with Prader-Willi syndrome are infrequent, and with close monitoring, GH therapy is considered to be generally safe in this population. Long-term GH treatment is known to improve body composition, muscle size and quality and increases muscle strength and exercise independently from the GH secretory status. Although GH therapy is clinically indicated for children with Prader-Willi syndrome, there is no specific brand name that has been shown to be more efficacious or that result in a lower rate of adverse effects. Given that the Health Plan has Nutropin AQ Nuspin pen injector, the request for Genotropin has not been established as medically necessary for treatment of the 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 hydrocodone-acetaminophen 5 mg-325 mg tablets, quantity 30. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested medication quantity in this patients case. Additionally, there is no documentation of completion of physical and behavior therapy, despite much research to support their use. It is also reasonable to consider alternatives to opioids and to taper the patient to a lower dose of opioids or even off opioids. Furthermore, there are no objective treatment goals for pain and function noted for the requested medication and medication quantity. The Centers for Disease Control and Prevention (CDC) guideline states that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. When opioids are started, clinicians should prescribe the lowest effective dosage. Also, multiple minimal requirements for opioid prescribing have not been done and the need to use them as the primary medication treatment strategy for pain, in this patients case, has not been established. Finally, not all non-opioid medications classes have been optimized or tried. For all these reasons, the requested authorization and coverage for hydrocodone-acetaminophen 5 mg-325 mg tablets, quantity 30, is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 authorization and coverage for Entresto 49 mg - 51 mg tablet. Findings:  The physician reviewer found that the documentation provided does not support the requested medication in this clinical setting. Based on the records provided, the patient has mitral valve repair and a cardiomyopathy. Left ventricular ejection fractions are reported at greater than 35% (most recently 41%). Additionally, the documentation does not support any ongoing heart failure symptoms or findings of heart failure on physical examination. In this circumstance, with most recent ejection fraction of greater than 40% and no documented ongoing signs or symptoms of congestive heart failure, treatment with Entresto is not medically indicated and not considered standard accepted practice. Entresto is considered medically appropriate in patients with ongoing New York Heart Association class II or class III congestive heart failure and left ventricle ejection fraction at 40%. The documentation provided does not support the clinical criteria for Entresto. For these reasons, Entresto 49 mg - 51 mg is not medically necessary for treatment of this patients medical condition. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for low level laser therapy for treatment of the enrollees recurrent breast cancer with lymphedema. Findings:  The 3 physician reviewers found that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has chronic lymphedema, which is difficult to treat due to chronic fibrosis. Low level laser therapy is a photochemical treatment used for soft tissue injury, chronic pain, and wound healing. Results from a randomized, single crossover trial of the treatment of patients with post-mastectomy lymphedema with low level laser therapy was found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately 33% of patients with post-mastectomy lymphedema at three months after treatment. Given the support in the peer-reviewed literature, the request for low level laser therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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.