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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rhizotomy (radiofrequency neurolysis of the left-sided facet joints at L3-S1). Findings:  The physician reviewers found that lumbar medial branch radiofrequency ablation or neurolysis has been demonstrated to be effective in well selected patients with chronic low back pain due to lumbar facet pain. Medial branch radiofrequency neurotomy in the lumbar spine can produce results that last from months to one year. This patients provider noted that he is sure that the facets on the left is the patients pain generator without having to repeat medial branch blocks. With the prior success of radiofrequency ablation on the left side from L4 to S1, the requested rhizotomy (radiofrequency neurolysis of the left-sided facet joints at L3-S1) is supported as 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 requested service 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:  One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  One Reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  All three 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: The step-wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. There is no documentation of the completion of behavior therapy despite significant research to support its use. In addition, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. For these reasons, the requested oxycodone 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 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 Gelsyn. Findings:  The physician reviewer found that there is a general lack of reliable evidence that any specific brand of viscosupplementation is superior to others. However, some clinically important reductions in pain have been noted, after closer review of systematic reviews and meta-analyses, using higher-molecular weight and cross-linked formulations. Synvisc and Synvisc One are cross-linked with molecular weight 5-6M (million Daltons). Euflexxa (2.4-3.6M) and Orthovisc (1-2.9M) are not cross-linked. Nationally recognized evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for severe knee osteoarthritis for patients who have not responded adequately to conservative treatment, in order to potentially delay total joint replacement. Higher quality studies have shown the magnitude of improvement to be modest. Per the medical evidence, if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high-quality scientific evidence. This patient presents with a history of left knee osteoarthritis with current severe pain and swelling. Clinical examination findings are consistent with reported imaging evidence of severe osteoarthritis. He has failed conservative treatment, including corticosteroid injection, exercise, and nonsteroidal anti-inflammatory drugs. He also reportedly failed prior viscosupplementation with Synvisc. Current evidence-based medical guidelines and peer-reviewed literature generally support the use of viscosupplementation for treatment of osteoarthritis of the knee and state that there is a general lack of reliable evidence that any specific brand is superior to others. The records do not document that the other formulary medication Monovisc has been tried. There is no compelling rationale presented to support the medical necessity of Gelsyn over the formulary viscosupplementation agent Monovisc. Additionally, prior viscosupplementation had not provided significant improvement in symptoms for six months or more to support the medical necessity of another series. Therefore, Gelsyn is not medically necessary for the treatment of this patient.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 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: The patient presents with transtibial and transfemoral amputations. The submitted documentation fails to demonstrate the medical necessity of the requested equipment. A plan for implementation of a power wheelchair has not been documented, and there is no physician order or rationale for a power wheelchair in this patients case. The patient must be able to safely use the device. Per the documentation, the patient reports painful contractures in hands that limit usage of a manual wheelchair. However, the records do not adequately document these contractures and their impact, if any, on mobility. All told, the requested power wheelchair is not medically necessary for the treatment of this patient.MD AnalysisFinal Result: The reviewer determined that the requested equipment 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. According to the most recent guidelines, all patients with chronic HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive, genotype 1 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 (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection, regardless of fibrosis stage. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as 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: A 56-year-old male enrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. 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 HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive, genotype 1 patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Zepatier 50-100 mg tablets for 12 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance angiography (MRA). The medical records do not document a family history of aneurysm. In addition, there are no records indicating increased risk of vascular disorder and there is no indication of inflammatory response involving the vessels. MRA is supported when there are focal neurologic findings consistent with disruption of blood flow in distribution of a cerebral vessel or suspicion of inflammatory response or family history of cerebral aneurysm. Medical literature supports MRA of head when there are focal neurologic findings in the setting of trauma or suspected trauma or underlying collagen vascular disorder. Medical literature noted that MRA is of limited use in evaluation of headache without focal neurologic finding. Researchers reported MRA may be considered in patients with focal neurologic findings supporting vascular disruption but is not supported for migraine headache evaluation. All told, the MRA performed on 12/7/17 was not medically necessary for the evaluation of the patient based on the medical records provided for review. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for prothrombin G20210A (factor II) mutation testing. Findings:  The physician reviewer found that there is a lack of support in evidenced based literature for the services at issue in this clinical setting. Unselected population based screening for inherited thrombophilia is not recommended because of low frequency of the symptomatic condition in the general population, and the low penetrance of the symptomatic condition among carriers of the most common thrombophilic conditions specifically, factor V Leiden and prothrombin G20210A mutations. In addition, a safe, long-term method of prophylaxis, if an abnormality is found, is lacking. While patients with a family history of thrombosis are at increased risk for a mutation, a simple positive history is not a reliable criterion to select patients for screening. The documentation provided for this review do not support a significant personal history nor a family history of thrombosis. Consumptive coagulopathy related to the angiolipomas does not necessitate factor II mutation testing. For these reasons, prothrombin G20210A (factor II) mutation testing was not likely to have been more beneficial than the available modalities of evaluating this patient. Final Result: All three reviewers determined that 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: All three reviewers are board certified in internal medicine with sub-specialty certification in hematology and are actively practicing. All three 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: A male enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees pancreatic cancer.The request for SBRT has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical records submitted for review, in addition to national consensus group guidelines, support the requested services in this clinical setting. Medical literature endorse the use of SBRT in the treatment of pancreatic cancer patients with locally advanced disease without metastases and reasonable performance status. In addition, guidelines also endorse the use of SBRT for the treatment of unresectable pancreatic cancer. The main benefit to SBRT is that the patients can be treated in five fractions versus the standard 28 fractions. Therefore, SBRT 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 requested services 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 reviewers 1, 2 and 3 are board certified in radiation 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 Avastin 743 mg The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of cervical carcinoma.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for proton beam radiation therapy. Findings:  Three physician reviewers found the current medical evidence has not demonstrated the superior efficacy of the requested services over photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure with this regard. However, this does not appear to translate into actual decreased clinical side effect. Cancer control rates are also reportedly similar between photons and protons. National Comprehensive Cancer Network guidelines support the use of proton therapy as a reasonable alternative to x-ray based regimens at clinics with appropriate technology, physics, and clinical expertise, but with the caveat that no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. All told, the requested proton beam radiation therapy is not likely to be of greater benefit than other available treatment options.  Final Result: The reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in radiation 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 Mavyret 100 mg - 40 mg tablets for the duration of eight weeks 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 1b 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 (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. All told, Mavyret 100 mg - 40 mg tablets for the duration of 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for confocal microscopy for evaluation of the enrollees atypical nevus syndrome. Findings:  The physician reviewer found that while confocal microscopy may yield a correlation with evaluation of atypical moles and melanoma, it is not standard of care for treatment of patients diagnosed with atypical moles.  The medical studies have not shown that this modality is superior to standard treatment protocols. There is a lack of evidence to indicate that it is more beneficial than standard follow up examinations and biopsies of suspicious lesions. As such, confocal microscopy is not likely to be superior over the available standard techniques of evaluating this patient. Final Result: Two of the three reviewers determined that requested services are 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 reviewers are board certified in dermatology and are actively practicing. All three 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.