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

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for pain medications, Fentanyl Patch 125 mcg/hour every two days and Norco 10/325 one pill up to eight pills per day. The Health Plan has denied this request indicating that the requested medication dosages are not medically necessary for treatment of the enrollees chronic low back pain.The submitted documentation fails to demonstrate the medical necessity for the requested medication dosages in this clinical setting. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. The need to use opioids as the primary medication treatment strategy for pain has not been established. The CDC guidelines state that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long acting (ER/LA) opioids. They should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 MME per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  In this case, the patient was recently taking 230 MME/day and 380 MME/day before the taper was started. There is no medical evidence based rationale provided by the provider or the patient for the requested dosages. Risk and benefit analysis must be done to justify the requested level of 380 MME/day. It is unclear what the plan is for any unseen future pain insults the patient would experience while on 380 MME/day. Moreover, non opioid medications classes have not been optimized or tried. For all these reasons, Fentanyl Patch 125 mcg/hour every two days and Norco 10/325 one pill up to eight pills per day are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication dosages 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac ablation procedure utilizing the minimal fluoroscopy approach.  Findings:  Two of the three physician reviewers found there is a lack of support for the requested services in this clinical setting. This patient is being evaluated for cardiac ablation of atrial fibrillation/flutter. In this circumstance, if ablation were thought to be necessary, then standard ablation protocols using fluoroscopy have been shown to be safe and efficacious. Therefore, the requested cardiac ablation procedure utilizing the minimal fluoroscopy approach is not likely to be of greater benefit than other 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: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling (Oncotype DX prostate cancer assay). The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees prostate cancer.Findings: There currently are three major approaches to the management of localized prostate cancer. These include surgery, various forms of radiation therapy, or active surveillance, with no specific anti-cancer treatment being given. Recommendations as to these options are based on risk stratification, which will estimate the risk for the future development of progressive cancer. Various features of an individuals cancer are put into this assessment, particularly the pathologic details and the PSA. By such categorization, this patient would be placed in a low to intermediate risk (if there was no Gleason 3+4 score, he would be considered low risk). Even if one places him in the intermediate risk category, he would fall into a sub-group (favorable intermediate risk). The current recommendation in this category is for active surveillance. A further refinement of such prognostics is the use of gene panels, such as Oncotype. This is a 17 gene panel that is capable of predicting recurrence after treatment for prostate cancer. Most importantly, a study of 395 men who had low to intermediate risk cancer later underwent prostatectomy. A significant proportion of patients had high grade or non-organ confined disease at surgery, and this correlated with their Oncotype score. The current literature indicates that the genetic test is useful in identifying treatment options for some patients who otherwise appeared to have surveillance eligible disease. As such, gene expression profiling (Oncotype DX prostate cancer assay) was likely to have been more effective than other methods of evaluating this patients medical condition.Final Result: All three reviewers have determined the services at issue were 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Mavyret 100 mg-40 mg for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients chronic hepatitis C virus (HCV), genotype 3a. The submitted documentation supports the medical necessity of the requested medication regimen. 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 3 patients should be treated with Mavyret for eight weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100 mg-40 mg for 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for bilateral Synvisc One injections. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients primary bilateral osteoarthritis of the knees. The submitted documentation does not support the medical necessity of the requested medication. Evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to corticosteroid injections. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome (kneecap pain), or osteochondritis dissecans. This patient presents with a recurrence of bilateral knee pain. Functional limitations were noted in mobility and activities of daily living. Prior Synvisc One injections reportedly resulted in in pain reduction and improved functional mobility. However, there is no documentation of a specific clinical examination or discussion of radiographic findings to support the presence of medial and/or lateral compartment osteoarthritis. The treating provider documented a diagnosis of patellofemoral arthritis. Current evidence-based guidelines and literature support the medical necessity of hyaluronic acid injections for the treatment of medial and/or lateral compartment arthritis. However, the medical evidence does not support the medical necessity of these injections for patellofemoral arthritis. Therefore, the requested bilateral Synvisc One injections are not medically necessary for the treatment of the 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Botox injections. Findings:  Three physician reviewers found the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Pooled results of two large, randomized, placebo-controlled trials show that Botox is an effective, safe, and well-tolerated treatment for the prevention of headache for patients with chronic migraine. In addition Botox has been approved by the U.S. Food and Drug Administration  for headache prophylaxis in patients with adult chronic migraine who suffer headaches on 15 or more days per month, each lasting more than four hours. The medical records report that this patient is having chronic headaches, migraine type, on an ongoing basis demonstrating headaches lasting four or more hours on 15 days or more per month for at least three months. Given these findings, the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the Botox injections were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in neurology 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 lumbar arthroplasty. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. This patient presents with a longstanding history of low back pain with current left lower extremity symptoms into the calf and dorsum of the foot. Clinical examination documented positive nerve tension signs and sensory deficit consistent with electrodiagnostic evidence of S1 radiculopathy. Imaging documented single level degenerative disc disease at L5-S1 with a left disc herniation abutting the L5 nerve roots and traversing left S1 nerve root. There is no evidence of spondylolisthesis or facet arthropathy. Evidence-based guidelines do not recommend artificial disc replacement for patients with evidence of nerve root compression. The U.S. Food and Drug Administration (FDA) approval document for the ProDisc-L device states that patients with radicular compression syndromes, especially due to disc herniation, are to be excluded from use of this device. This patient presents with clinical examination and imaging and electrodiagnostic evidence of S1 nerve root compression which would be an exclusion from the use of this device. Therefore, the requested lumbar arthroplasty is not medically necessary for the 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 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: A 30-year-old male enrollee has requested authorization and coverage for Mekinist 2 mg. As noted in the medical literature, the safety and effectiveness of MEK inhibition in thymic carcinoma has not yet been demonstrated in clinical trials. In addition, the use of molecular profiling for guiding treatment for thymic carcinoma remains unknown. Overall, standard therapies such as immunotherapy have been shown to be more effective in this clinical setting. In a phase II study, researchers reported on 40 patients with stage IV thymic carcinoma and at least one prior line of systemic therapy. The patients were treated with pembrolizumab for up to two years. There were nine objective responses, including one complete response. All told, the requested Mekinist 2 mg is not supported as medically necessary for treatment of this patients thymic 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab (Rituxan).  The Health Plan has denied this request indicating that the requested medication is considered investigational for treatment of the enrollees membranous nephropathy.Findings:  There is support in the medical literature for the requested medication in this clinical setting. Rituximab is an accepted therapy for membranous glomerulonephritis and is considered a standard of care. The documentation provided supports the use of rituximab in this patient. Moreover, peer-reviewed literature has indicated the efficacy of rituximab for treatment of membranous glomerulonephritis. This patient has failed Ponticelli protocol and has documented persistent proteinuria. Therefore, rituximab (Rituxan) is more likely to be a greater benefit over the standard therapy for the treatment of this patients medical condition. Final Result: All three reviewers have determined that the requested medication is likely to be more beneficial for treatment of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in nephrology 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:  An enrollee has requested reimbursement for positron emission tomography for evaluation of the enrollee who has a history of breast cancer and neurocognitive disorder.  Findings:  The physician reviewer found that Mild cognitive impairment (MCI) is a clinical presentation that is in the transitional stage between normal aging and frank dementia. When memory loss is the predominant symptom, it is referred to as MCI amnestic type. One distinguishing factor from Alzheimers disease is that patients with MCI with generally have preservation of general cognitive and functional abilities. Neuroimaging has helped to narrow the differential diagnosis. Most patients will initially have either a computed tomography scan (CT) or magnetic resonance imaging (MRI) study of the brain. These studies provide structural or anatomic information, and are useful in excluding such entities as tumors, strokes, subdural hematomas, or normal pressure hydrocephalus. But they do poorly in evaluating metabolic abnormalities. On the other hand, functional evaluation of the brain is best performed with PET/CT scanning which generally report higher accuracy (Davison, et al). The patient was also evaluated for routine follow up for her breast cancer in December. At that time, she had no symptoms directly referable to her breasts or possible metastases. While it is accepted that the early initial detection of breast cancer greatly increases the likelihood of survival and cure there is a lack of data demonstrating that early detection via surveillance imaging studies provides substantial benefit as opposed to watchful waiting. In conclusion, there is considerable literature supporting the use of PET scanning in the evaluation of possible dementia. As such, the PET scan provided  was likely to have been more efficacious in the evaluation of this patients condition than the available standard modalities, while the use of PET scan provided for the routine surveillance follow up of breast cancer was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers have determined that a portion of the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  All three reviewers are board certified diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for LINX procedure. The Health Plan has denied this request indicating that the requested services are considered investigational for treatment of the enrollees medical condition. Findings: There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. Sheu and colleagues concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. Another best evidence review concluded that long-term comparative outcome data past [one] year are needed in order to further understand the efficacy of magnetic sphincter augmentation (Skubleny, et al). Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration approval (Bauer, et al). One peer-reviewed journal published a letter stating that there have been reports of endoscopically confirmed LINX erosion through the esophagus in the U.S. Food and Drug Administration (FDA) Adverse Events database (Bielefeldt). Additionally, LINX more than surgical fundoplication is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial than standard treatment, surgical fundoplication. The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). For these reasons, LINX is not likely to be of greater benefit than the available standard options for the treatment of this patients medical condition.Final Result: Two of the three reviewers have determined that the requested procedure is 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 reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.