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 surgery to remove an adenosarcoma tumor for treatment of her metastatic cancer. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Given the extent of the disease in the pelvis and involvement of ureters and small bowel, the tumor is likely unrespectable. It is unlikely that any component of the operation would successfully palliate her symptoms of ureter and bowel obstruction. Given her poor functional status, she would have a very high risk of operative morbidity, such that even if the operation accomplished some goal of palliation, she would be unlikely to achieve an overall improvement in her quality of life.  Final Result: The reviewers 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 surgery with sub-specialty certification in complex general surgical 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for steroid injections.  Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  This patient has symptoms of lumbar radiculopathy. Per the records, MRI demonstrated a caudally extruded right paracentral disc herniation abutting the right S1 nerve root as well as degenerative changes in other lumbar discs and facet arthropathy.  She has had trials of conservative therapy which have not improved her pain. The injections  provided produced 70% pain relief. The medical evidence supports epidural steroid injections in this patients case. Clinical practice guidelines support performing an epidural steroid injection in the presence of lumbar radiculopathy where prior injections have been documented to provide 50% pain relief for a significant period of time, as in this case.  Therefore, the requested steroid injections are medically necessary for the treatment of this patient. Final Result: The reviewers 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: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter placement of intravascular stent for treatment of the enrollees bilateral carotid disease. Findings:  Two physician reviewers found that There is sufficient support for the requested services in this clinical setting.  The patient has coronary disease, hypertension, hyperlipidemia and severe, symptomatic carotid stenosis. Per the current guidelines, for symptomatic, high risk patients with severe carotid stenosis, carotid stenting is considered a class IIA indication, with the weight of evidence in favor of treatment.  Carotid stenting is reasonable as it is a less invasive, safer alternative to surgery for this patient. Thus, the requested transcatheter placement of intravascular stent is likely to be more efficacious than other treatment options. Final Result: The 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: Reviewer 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: The parent of a 13-year-old enrollee has requested somatropin growth hormone (GH) therapy for treatment of the enrollees short stature. Findings:  The physician reviewer found that the records provided for review do not demonstrate that this patient has classic GH deficiency, as he had a normal result on GH provocative testing, and his IGF-1 level is normal for bone age. He has no known morphological abnormalities of his pituitary gland and no biochemical evidence of pituitary hormone deficiencies. Based on the patients height and bone age, his estimated final adult height is just over 65 inches, which is appropriate for his genetic potential and within normal limits for U.S. adult males. The most likely reason for a fall-off in height is constitutional delay. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or insulin like growth factor binding protein 3 (IGFBP-3); and/or (5) other clinical features suggestive of GH deficiency. This patient does not meet these criteria based on the records provided for review. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Repatha 140 mg/ml for treatment of his hyperlipidemia. Findings:  The physician reviewer found that the patient has documented coronary disease and persistently high LDL cholesterol despite maximally tolerated statin dose in combination with both Zetia and fenofibrate.  Repatha is a proprotein convertase subtilisin kexin 9 (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient fits the latter criteria.  There are randomized clinical trials that document significant LDL lowering with PCSK9 inhibitors in patients with the above criteria in addition to cardiac outcome improvement in post-hoc analyses.  The medical evidence supports the requested medication in this clinical setting.  Final Result: The reviewers 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 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: An enrollee has requested Cialis 20 mg for treatment of his erectile dysfunction. Findings:  The physician reviewer found that erectile dysfunction is a common medical condition in men over 50 years of age, with aging being the most common etiology for vascular disease leading to erectile dysfunction. Phosphodiesterase type 5 (PDE5) inhibitors are first line therapy for treatment of erectile dysfunction.  Multiple PDE5 inhibitors are available on the market. These include Viagra, Levitra, Cialis and Stendra. They have unique pharmacokinetic profiles and side effects. This patient has been treated with Cialis since 2012 and has had an adequate response. Hence, continued treatment with Cialis is medically necessary for this patient. Final Result: The reviewers 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 urology 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 heart valve surgery (transcatheter valve repair) for treatment of her complex congenital heart disease. Findings:  Two physician reviewers found that based on the records provided the patient has a history of tetralogy of Fallot who has residual high volume pulmonary regurgitation leading to progressive right ventricular enlargement and likely contributing to ventricular dysrhythmias. In this circumstance, pulmonary valve replacement is reasonable, appropriate and considered standard accepted practice in the medical community.  Patients with complex congenital heart disease require several surgeries over a lifetime so minimizing the number of surgeries is essential. With recent advances certain patients who require pulmonary valve replacement can be safely and effectively treated percutaneously such as this patient with a small pulmonary annulus. The proposed procedure has documented success in the peer-reviewed literature and has become an accepted approach in patients with suitable anatomy such. 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 is 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 stress echocardiogram for evaluation, who presented to her provider for annual examination. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the services at issue. Based on the records provided,the patient has been diagnosed with an isolated right bundle branch block. However, there were no documented symptoms concerning for any acute cardiac condition, no documented cardiovascular physical examination abnormalities and no documented chest radiographic abnormalities. In this circumstance, the medical records provided to not support the need for obtaining a stress echocardiogram. An isolated right bundle branch block without any other documented abnormalities is generally benign and is not an accepted indication for stress testing.  Current guidelines, endorsed by several national organizations, also do not consider stress echocardiography appropriate in this clinical setting. Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for chiropractic care twice per month for treatment of the enrollees scoliosis. Findings: The physician reviewer found that according to reviews of current literature, there is a paucity of data demonstrating the efficacy of manual therapy, chiropractic and osteopathy in the treatment of idiopathic scoliosis. The majority of studies have poor methodology or are observational case studies. At present, non-specific manual therapy has not been shown to be beneficial for patients with idiopathic scoliosis. Further prospective, randomized, controlled studies are needed in order to reliably assess the usefulness of non-specific manual therapy in the treatment of idiopathic scoliosis. 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 a board certified chiropractor 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 removal of right breast implant Findings:  The physician reviewer found that The documentation submitted does not support the medical necessity for the procedure at issue. The patient described a history of back pain, but the plastic surgery review of systems does not describe back pain. The patient also reported that she has had several surgeries related to the left breast infection. Per the patient, she was not a good candidate for left breast replacement implant because of weak skin tissue. Per the consultation note, the patient reported a concern about breast asymmetry. The plastic surgery note does not document any issues with back pain. Furthermore, a work-up for back pain was not documented. The records do not support the medical necessity for the procedure at issue. Instead, the right breast implant removal appears to primarily enhance breast symmetry. As such, removal of right breast implant performed was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the procedure 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 plastic 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:A 70-year-old male enrollee has requested authorization and coverage for Ofev.Findings:  The physician reviewer found that the patient is noted to have idiopathic pulmonary fibrosis, chronic respiratory failure, and obstructive sleep apnea syndrome per the provider. This patient was on Esbriet for 10 months with no response. The provider recommended treatment with Ofev due to failure of Esbriet. The Health Plan denied coverage for Ofev. Per the Health Plan, the requested medication is investigational for treatment of this patient. The medical literature supports the superior efficacy of Ofev in this clinical setting. This patient has a high resolution computed tomography of chest taken in the previous year. This scan showed extensive bilateral interstitial thickening and bibasilar bronchiectasis, which is compatible with idiopathic pulmonary fibrosis (IPF) and not compatible with other conditions even in the presence of a few right pleural calcifications. Likewise, the age, sex, clinical picture, and the pulmonary function tests from several months previous are all compatible with IPF as well. Of note, this patients forced vital capacity is less than 50%, indicating this patient has severe disease. There is a lack of other specific treatment for this patients medical condition. He has failed treatment with Esbriet. In sum, the Ofev is likely to be more beneficial for treatment of this patients medical condition than other treatment options. Final Result: The reviewers  determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are 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 Decision DX Melanoma Gene Expression Assay testing for evaluation of his melanoma. Findings:  Three physician reviewers found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch.  Mitotic index may also add more to these statistics. By Balch staging, this patients melanoma would be classified as a T1a, or stage 1A assuming the sentinel node was negative, if done. By Balch tables, he would have had at least an 88% chance for ten-year survival.  Decision DX is a study of 31 genes in an individuals melanoma cells. It then classifies that particular melanoma as either Class 1 (with a 97% disease free survival at five years), or Class 2 (with a 31% disease free survival at five years). Researchers reported on 217 cases, with good correlation between Decision DX classification and prognosis, in patients undergoing sentinel node sampling. However, it is not clear how the five year Decision DX data compares to the ten year Balch data, and, most importantly, whether it can be used additionally to make 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: Reviewer 1, 2, and 3 are 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that according to the 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that genotype 1b patients who have failed peg-interferon and ribavirin should be treated with regimens including Zepatier for 12 weeks. These guideline recommendations are based on clinical trial results showing a 94% cure rate. While both Zepatier and Viekira are recommended as first-line therapy, neither is reported to be superior by the guidelines. Overall, no head-to-head comparison has shown the superiority of Viekira over Zepatier in this patient population. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for intensive outpatient program services provided and  forward.  Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  The progress notes indicate the patient has made improvements behaviorally. However, he continues to have aggression.  It appears that he is receiving evidence-based treatment for the management of his behavioral health conditions.  The records indicate that the patient continues to need this level of care in order to manage his poor social skills, impulsivity, and aggression. The current medical evidence supports intensive outpatient program services in this patients case.  Per the clinical notes, the patient has not stabilized, and his current behavioral issues are only minimally improved.  All told, intensive outpatient program services provided forward were and are medically necessary for the 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 sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition