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

The patient has requested authorization and coverage for bevacizumab 10 mg injections in combination with TAS-102. TAS-102 is a newer compound that has been demonstrated to improve overall survival in patients with refractory metastatic colon cancer when compared with placebo. Further study has shown that this positive response is further improved with the addition of Avastin. Researchers found that their findings suggest that the addition of bevacizumab to the chemotherapy regimen could be an efficient and safe treatment option for patients with metastatic colorectal cancer as second-line therapy and without increasing the risk of adverse event. This patient has metastatic colorectal cancer that has progressed despite treatment with FOLFOX with bevacizumab and FOLFIRI with bevacizumab. Given the support in the medical literature, the requested bevacizumab 10 mg injections in combination with TAS-102 are medically necessary for 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 subspecialty 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

The patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient meets the six ASAM dimensions to support treatment in a Level 3.1 RTC. Therefore, the RTC services were and are medically necessary for treatment of this patient.Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874). The National Comprehensive Cancer Network (NCCN) guidelines state that, perirectal spacer materials may be employed when the previously mentioned techniques are insufficient to improve oncologic cure rates and/or reduce side effects due to anatomic geometry or other patient related factors, such as medications or comorbid conditions. This patients documentation does not support that daily prostate localization could not be performed using routine techniques. There is no report of anatomic geometry or other patient-related factor increasing the likelihood of these side effects. All told, the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Two of the three physician reviewers found the insertion of perirectal spacer with SpaceOAR Hydrogel (CPT 55874) was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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: The patient has requested authorization and coverage for Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day. In this case, the patient has medical problems including hyperlipidemia, hypertension, migraine headaches and chronic twitching of the eyelid. The medications including Crestor (rosuvastatin), Diovan HCTZ (valsartan/hydrochlorothiazide), Relpax (eletriptan) and Klonopin (clonazepam) are medically appropriate treatment for her medical conditions. However, the records provided for review do not support the medical necessity of the brand name formulations of these medications. Specifically, the documentation does not report that the patient has experienced any adverse reactions to the generic equivalents of these medications. When the U.S. Food and Drug Administration (FDA) approves a generic drug product, it has met rigorous standards with respect to identity, strength, quality, purity and potency. Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product. The generic drug manufacturer must prove its formulation of the medication is bioequivalent to the brand name drug. Through review of bioequivalence data, the FDA ensures that the generic product performs the same as its respective brand name product. Therefore, the requested Crestor 5 mg once a day, Relpax 40 mg once a day, Diovan HCTZ 80-12.5 mg once a day, and Klonopin 0.5 mg once a day are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal 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

The patient has requested authorization and coverage for transcatheter aortic valve replacement (TAVR) surgery. Based on the available documentation, this patient has severe aortic stenosis by echocardiography and he reports symptoms of increasing fatigue, which are consistent with the marked severity of his aortic valve disease. As he is symptomatic, he meets criteria for aortic valve replacement as a D1 classification as a low-risk surgical patient. Based on his other anatomic studies, he is a good candidate for transcatheter aortic valve replacement by technical criteria. Moreover, the U.S. Food and Drug Administration (FDA) has approved TAVR surgery for low-risk symptomatic surgical patients who require aortic valve replacement. Given this support, the requested TAVR is medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested surgery 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 subspecialty 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: Upheld Decision of Health Plan

The enrollee is requesting authorization and coverage for Cutaquig. The enrollee has a history of autoimmune thyroiditis and immunoglobulin G subclass deficiency. The physician recommended continued intravenous immunoglobulin G therapy. The physician reported the enrollee is at an elevated risk due to the COVID-19 crisis, and that the enrollees severely compromised immune system cannot protect her from this virus. This enrollee is diagnosed with immunoglobulin G subclass deficiency, but the only subclass that is low is immunoglobulin G-4, which is low in a small percentage of enrollees with no immune dysfunction.  In addition, the immunoglobulin G-4 level in this enrollee is two, whereas a level of less than or equal to one is typically considered low.  Literature recommends the primary treatment for immunoglobulin G subclass deficiency is treating any concomitant allergy, using prophylactic antibiotics, and then judicious use of polyclonal human immunoglobulin G in selected enrollees. This enrollee has not received the former treatments yet; therefore, not a candidate to start immunoglobulin replacement therapy at this time. Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in allergy and immunology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The enrollee requested coverage for romiplostim subcutaneous injections. The enrollee has congenitally large platelets and was tested for the MYH9 gene mutation (May Hegglin line of disorders). There are not a large number of articles that exist to establish an absolute platelet standard in sports for immune thrombocytopenia (ITP) patients; therefore, clinical judgement is required for treatment of inherited thrombocytopenia derived from the MYH9 mutation in patients with platelets less than 100,000. According to literature available, due to severe risk for internal bleeding with ITP patients in high contact sports, they should not play with platelet counts less than 100,000/uL. This patient had borderline platelet counts of 103,000/uL and they likely will drop below this at varying times. Due to his occupation and above guidelines, the current standard hematologic treatment, including treatment with Romiplostim, would be based on the fluctuation of platelet count and not solely on two platelet counts over 100,000/uL. Romiplostim should be given here due to the patients high risk for bleeding in his profession. Final Result: The reviewer determined that the requested medication is medically necessary for the treatment of the enrollees medical condition.Credentials/Qualifications: The physician reviewer is board certified in hematology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

The patient has requested authorization and coverage for high-intensity focused ultrasound (HIFU). Based on current peer-reviewed medical literature, there is a paucity of data to support an indication for treatment with HIFU for this patients low risk prostate cancer. There are limited prospective randomized controlled studies comparing HIFU with other standard treatment approaches. Moreover, the current guidelines from the American Urological Association (AUA), American Society for Radiation Oncology (ASTRO), and Society of Urologic Oncology (SUO) do not recommend HIFU for the initial management of patients with prostate cancer. The U.S. Food and Drug Administration (FDA) has approved HIFU for the destruction of prostate tissue. However, HIFU has not received FDA approval for the treatment of prostate cancer. Given these findings, the requested HIFU is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certifications in medical oncology and hematology 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

The enrollee is requesting authorization and coverage for Ferriprox. The enrollee has sickle cell disease, and hemochromatosis due to repeated blood transfusions and transfusion iron overload. Other diagnoses include chronic kidney disease, stage 3b-4, and hypertension. His physician is requesting Ferriprox to treat iron overload. There is considerable experience with iron chelation therapy in hemoglobinopathies where organ and total body iron has been shown to prevent organ iron deposition and dysfunction. Hereditary sickle cell disease is a hemoglobinopathy. Phlebotomy to reduce iron overload cannot be done in sickle cell disease due to anemia, so iron chelation therapy is needed and has proven beneficial.  Deferiprone (Ferriprox) is a more recent approved chelation therapy for iron overload in enrollees with hemoglobinopathies.Final Result: The reviewer determined that the requested service is medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician reviewer is board certified in hematology 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The patient has requested authorization and coverage for narrowband ultraviolet-B (NVB) radiation three times per week. Psoriasis is a chronic skin disease that can cause significant flaking of the skin, pruritus, and social distress. The records provided for review document the presence of severe psoriasis with these associated symptoms. Treatment of this chronic disease can include NVB, which is effective with few side effects. However, effective treatment requires scheduling of NVB treatment three times per week for several months. According to the National Psoriasis Foundation (NPF), phototherapy serves as a reasonable and effective treatment option for patients requiring more than topical medications, patients who need to avoid systemic medications, or those seeking an adjunct to a failing treatment regimen. The NPF reports that NVB treatment three times a week treatment resulted in an average clearance of 58 days. This patient has experienced excellent results with NVB treatment in the past. Given these findings, the requested NVB radiation three times per week is medically necessary for 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 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

The patient has requested reimbursement and prospective authorization and coverage for substance abuse subacute rehabilitation residential treatment center (RTC) services. Per the American Society of Addiction Medicine (ASAM) criteria, this patient meets Level 3.1 criteria for RTC services. ASAM criteria focuses on six dimensions to determine the appropriate level of care, which includes: (1) intoxication and withdrawal potential; (2) biomedical conditions; (3) emotional, behavioral and cognitive conditions; (4) readiness to change; (5) relapse, continued use, or continued problem potential; and (6) recovery environment. Given the findings, the patient meets the six ASAM criteria for treatment at the RTC level of care. Accordingly, the substance abuse subacute rehabilitation RTC services were and are medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with subspecialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for captains chair seating. The records indicate that the patient has multiple areas of pain. He is obese and has difficulties with longer distance mobility. There are, however, no indications of pertinent neurological deficits. Strength has been rated as 4+ in the limbs. He is able to ambulate within his home, as would be generally recommended in order to maximize physical activity in the setting of his health conditions. The patient uses a power scooter for his longer distance mobility in the community. The records do not establish that the patient has impairments that require specialized seating instead of a standard seating system on his power scooter. Therefore, the requested captains chair seating is not medically necessary for the treatment of this patient.Final 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 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 Taltz 80 mg/mL autoinjectors. The America College of Rheumatology (ACR) recently released guidelines on the treatment of psoriatic arthritis. The ACR noted that for patients with active psoriatic arthritis despite treatment with a tumor-necrosis factor inhibitor (TNFi) biologic monotherapy, switching to a different TNFi biologic monotherapy is recommended over treatment with Taltz, which is an IL-17 biologic (Singh, et al.). In this case, the guidelines support treatment with a second TNFi. This patient has failed treatment with Enbrel, Cosentyx, sulfasalazine, leflunomide, and methotrexate due to intolerable side effects or lack of efficacy. She experienced a partial response to a TNFi in her joints and there is no contraindication to a trial of a second TNFi. Based on current data, Humira, Cimzia, and Otezla are supported as safe and effective for the treatment of psoriatic arthritis and the patients medical records do not report a contraindication to these agents. All told, the requested Taltz 80 mg/mL autoinjectors are not medically necessary for 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 internal medicine with subspecialty certifications in allergy and  immunology and rheumatology 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 4Kscore blood test (CPT 81539). The 4Kscore test incorporates four prostate-specific kallikrein assay results and clinical information to calculate an individual patients percent risk for aggressive prostate cancer on prostate biopsy. The 4Kscore test might be helpful for patients with an abnormal PSA or abnormal digital rectal examination (DRE) prior to initial or repeat prostate biopsy to identify the risk of high-grade prostate cancer. The National Comprehensive Cancer Network (NCCN) guidelines recommend considering a 4Kscore test prior to biopsy for patients with an elevated PSA and risk factors. However, the NCCN guidelines do not consider the test as the standard of care for all patients with elevated PSA. Furthermore, current data have not demonstrated that the 4Kscore improves patient health outcomes in randomized studies when compared to standard risk assessment. Hence, use of 4K score is not considered a clinically appropriate standard of care in the routine screening for prostate cancer in this patient with an elevated PSA, who has not undergone a prostate biopsy. All told, the 4Kscore blood test (CPT 81539) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three of the three physician reviewers found the 4Kscore blood test (CPT 81539) 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 services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in urology 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.