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 Repatha (evolocumab). Findings:  The physician reviewer found that based on the records provided the patient presents with an increased coronary risk but no documented coronary ischemia, no documented obstructive coronary stenosis and no documented clinical cardiac event.  Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. Studies that have demonstrated outcomes benefits with PCSK9 inhibitors such as Repatha in patients with a history of prior cardiovascular events. In this case, the patient does not fit either of the above criteria. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting . In addition, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. For the reasons provided, the request for Repatha (evolocumab) is not 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 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 patient has requested authorization and coverage for a deep brain stimulator. Findings:  The physician reviewer found that in the medical literature, a study reported that deep brain stimulation (DBS) is a viable therapeutic option for the treatment of chronic neuropathic pain. Another study concluded that DBS demonstrated efficacy at 1 year for chronic neuropathic pain after traumatic amputation and BPA. This patients records document that standard available treatment options have been attempted without success. Thus, the requested deep brain stimulator is supported as medically necessary for treatment of this patients BPA with neuropathic pain. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollees recto-sigmoid cancer. Findings:  Two physician reviewers found that the gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Genetic testing of a tumor offers a comprehensive panel of molecular genetic markers on an individuals tumor to identify markers than can help guide therapy decision making. Per the National Comprehensive Cancer Network (NCCN) guidelines it has not been determined that molecular markers are useful in treatment determination and prognosis other than KRAS, NRAS, and BRAF mutations. For the reasons provided, the testing at issue 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 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: 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 individual acupuncture for treatment of headaches, musculoskeletal pain and nausea. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. The records note a recent flare-up of her chronic neck, shoulder and lower back condition related to a fall. Due to the severity of the pain, medication was required which produced nausea and lightheadedness. Researchers described the effectiveness of complementary and alternative medicine therapies compared to placebo, no intervention, or other interventions for acute/subacute and chronic low back pain. The authors noted that acupuncture is more effective than no treatment for chronic low back pain. Other researchers performed a recent randomized controlled trial comparing usual care to acupuncture plus usual care. The authors found that at 24 months the acupuncture/usual care subjects were significantly more likely to report 12 months pain free and less likely to report they required use of medication for pain. As this patient described functional improvement and symptom reduction with prior six acupuncture sessions, the requested individual acupuncture is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in oriental 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 patient has requested authorization and coverage for left knee replacement surgery. Findings:  The physician reviewer found that this patients records do not support the medical necessity of the requested left knee replacement surgery. The patients poor health including obesity, poorly controlled diabetes, and heart failure with reduced left ventricular function make him high risk and a poor candidate for knee arthroplasty. In the medical literature, a study concluded that Morbid obesity significantly increased the risk of subsequent revision, reoperation, and reinfection following two-stage revision total knee arthroplasty for infection. another study reported that patients with heart failure are more likely to have a longer length-of-stay, return to the operating room, and be readmitted. Additionally, they have a higher risk for at least one postoperative complication, myocardial infarction, and wound dehiscence. Left knee replacement surgery is not medically necessary and appropriate for this patient with poor and deteriorating health.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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for laboratory testing for evaluation of ulcerative proctitis/left sided colitis. Findings:  Two physician reviewers found that there is a lack of sufficient medical evidence to support the effectiveness of the services at issue when compared with conventional courses of action in the management ulcerative colitis. The published studies on the use of anti-adalimumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the ATLAS study showed that patients with loss of response may actually have high, rather than low, serum levels.  It is possible that active disease results in low adalimumab levels due to loss of adalimumab, rather than low adalimumab levels resulting in loss of disease control.  Moreover, controlled studies are lacking to show that use of the test results in improved long term health outcomes for patients with ulcerative colitis compared with conventional management. For these reasons, there is not sufficient evidence from controlled studies to definitively demonstrate that the laboratory testing was likely to have been more beneficial than any available standard therapy for treatment of this patients 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 heart surgery to prevent stroke for treatment of the enrollees atrial septal defect (ASD). Findings:  Two physician reviewers found that based on the clinical documentation submitted for review, the request for heart surgery to prevent stroke is indicated due to the patients history of exertional dyspnea, large left to right shunt at the atrial level complicated by bi-atrial enlargement including severe left atrial enlargement. The patient has already developed bi-atrial enlargement as well as right ventricular enlargement which indicates that adverse hemodynamic consequences associated with the PFO have begun to occur. The patient has been treated with Eliquis. The medical literature review supports repair of the PFO for the prevention of further adverse and irreversible hemodynamic consequences. For the reasons provided, the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested surgery 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: 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: An enrollee has requested authorization and coverage for stab phlebectomy treatment of the enrollees varicose veins. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The treating provider did not provide sufficient information to justify the proposed treatment. This patient has deep and superficial reflux bilaterally. There are cases where phlebectomy alone may be appropriate, even with reflux present. However, the reasoning for such a decision is not supplied in this case. The medical evidence does not support the requested services in this clinical setting. 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 vascular surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcatheter closure of atrial appendage for treatment of the enrollees paroxysmal atrial fibrillation. Findings:  The physician reviewer found that the transcatheter closure of atrial appendage was not 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 needed treatment to prevent embolic stroke due to atrial fibrillation and was not able to take anticoagulants due to prior bleeding side effects. In this circumstance, treatment options included the Watchman device, the AtriClip or surgical ligation. Surgical ligation is considered standard therapy in this clinical setting. Device-based therapy such as the Watchman and the AtriClip are not supported in established guidelines, since outcome data is still being accumulated. Given the lack of support in the peer-reviewed literature, the transcatheter closure of atrial appendage was not likely to be more beneficial than standard therapy. Final Result: The reviewers determined that the surgery at issue was 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The representative of a patient has requested reimbursement for the molecular profiling for evaluation of the enrollees recurrent multicentric glioblastoma. Findings:  Two physician reviewers found that per National Comprehensive Cancer Network (NCCN) guidelines, molecular profiling is not helpful or necessary in making treatment decisions in this clinical setting. Molecular profiling offers a comprehensive panel of molecular genetic markers on an individual patients tumor in an attempt to identify markers than can help guide therapy decision making. Per the NCCN guidelines, it has not been determined if molecular markers are useful in treatment determinations. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. Final Result: The 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MiniMed G670 insulin pump and continuous glucose monitor hybrid closed-loop system. Findings:  The physician reviewer found that the MiniMed 670G system is U.S. Food and Drug Administration (FDA) approved for the management of type 1 diabetes mellitus in persons, 14 years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin. The MiniMed 670G System includes SmartGuard technology, which can be programmed to automatically adjust delivery of basal insulin based on continuous glucose monitor (CGM) sensor glucose values, and can suspend delivery of insulin when the sensor glucose value falls below or is predicted to fall below predefined threshold values. Studies have showed that the closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes . This feature is of critical importance to this patient with hypoglycemia unawareness, diabetes gastroparesis and status post stroke. In addition, studies also demonstrate the deleterious effect of wide glucose fluctuations as a factor in the development of diabetes related complications. In this case, the patient has neuropathy, so it is important to bring the paitents hemoglobin A1c (HbA1c) to 7% with no hypoglycemia. The MiniMed 670G is a closed-loop system insulin pump with CGM that will automatically make corrections when the patient is trending to hypo- or hyper-glycemic range. With this system, the patient will be able to keep HbA1c closer to goal and while minimizing hypoglycemic and hyperglycemic events. For the reasons provided, the request for MiniMed G670 insulin pump and CGM hybrid closed-loop system is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the requested device is likely to be more beneficial for treatment of your medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Decision Dx-Melanoma gene testing services for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that found the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index has also been thought to add a bit more to these statistics. By Balch staging, this melanoma would be classified as stage 1A, with an expected ten-year survival of at least 88%. Decision Dx-Melanoma gene testing is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 90 to 97% chance of disease free survival at five years), or Class 2 (with a lower rate of disease free survival at five years). Researchers reported on 217 cases, with good correlation between prognosis and Decision Dx-Melanoma gene testing classification in patients undergoing sentinel node sampling. This patient has not had such sampling. It is not clear how the Decision Dx-Melanoma gene testing five-year data compares to the ten-year Balch data and whether it can be used to make meaningful clinical decisions. 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: 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: An enrollee has requested reimbursement for an oral appliance for treatment of chronic headache. Findings:  The physician reviewer found that there is insufficient evidence in the medical literature to support the medical necessity for the device at issue in this clinical setting. This patient had presented with complaints of chronic headache, jaw pain and a compromised nasal airway. The patients orthodontist had assessed the patient for maxillary hypoplasia, maxillary asymmetry, mandibular discrepancy to cranial base, headache and jaw pain. The orthodontic provider recommended treatment beginning with palatal expansion. Palatal expansion is a treatment option, which is recognized to correct a patients dental malocclusion. However, the use of this device for the treatment for headache is uncertain and not well supported in the medical literature. Final Result: The reviewer determined that the device at issue was 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 oral and maxillofacial 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.