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

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for Xeljanz. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients seronegative rheumatoid arthritis with human leukocyte antigen, B27 (HLA-B27). The submitted documentation does not support the medical necessity of the requested medication. This patient has been diagnosed with seronegative RA. The American College of Rheumatology guidelines recommend methotrexate with or without tumor necrosis factor inhibitors as the next treatment in those who have failed methotrexate alone. There are potential longer-term safety concerns related to tofacitinib that need additional study. There are also multiple studies demonstrating efficacy and safety of tumor necrosis factor inhibitors (TNFi) over the years in treating moderate to severe RA. Per the medical evidence, a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. The medical literature indicates that there is a risk of reactivation of tuberculosis in patients treat with Xeljanz. There is a lack of comparison studies in patients with TB or previous TB demonstrating Xeljanz is safer than TNFi. As such, Xeljanz 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 internal medicine with sub-specialty certification in 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: 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 urgent exploratory surgery before 9/05/18. Undescended testis is one of the more common congenital anomalies. Although it can be associated with a congenital syndrome, it is most likely an isolated occurrence. Etiology is likely multifactorial, the result of both genetic and environmental factors. Transabdominal descent is complete by 10 weeks gestation, and inguinal descent is typically completed by 20 to 28 weeks gestation. The current standard of care is subspecialist referral in the event of undescended testis because spontaneous descent is unlikely after six months of age. Fertility potential is most likely to be preserved when surgical intervention occurs prior to 12 months. In this patients case, his provider was following standard guidelines of watching and monitoring until six months of age to see if the testis would descend spontaneously. At that point, the patient was appropriately referred to a pediatric urologist for evaluation. The surgical procedure is scheduled prior to the patients first birthday, which is also consistent with best evidence for preservation of fertility. While orchiopexy is medically necessary and appropriate before 12 months of age, in the absence of complications, it is not an urgent matter for this patient and does not need to be undertaken prior to 9/05/18. Therefore, urgent exploratory surgery before 9/05/18 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 pediatrics 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 Norco for treatment of the enrollees pain.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication. The records document chronic intractable headaches. However, this patient has been on a high dose of opiates that exceeds clinical practice guidelines and places her at risk for overdose. The use of other sedating drugs amplifies this risk. The medical evidence does not support the requested medication in this clinical setting. Therefore, Norco 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 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 AccuBoost for treatment of the enrollees breast cancer.Findings:  The physician reviewer found that found that this patient meets criteria for standard partial breast radiation. Standard techniques for partial breast radiation include external beam partial breast radiation, interstitial brachytherapy or balloon brachytherapy. There is a lack of phase 3 studies that have utilized the use of noninvasive image-guided brachytherapy.  The data examining the use of partial breast radiation has been with standard external beam radiation or invasive breast brachytherapy. Due to the lack of clinical data on the AccuBoost technique and uncertainties about its dosimetry, it is not likely to be more beneficial than standard techniques. Thus, AccuBoost (CPT codes 77770, 77771 and 77772) is not likely to be more effective than other treatment options. Final Result: Two of three physician 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hospitalization services and prospective authorization and coverage for continued acute rehabilitation services. Based on documentation from the treating providers, the patient was medically approved for transfer to a skilled nursing facility (SNF). There is no documentation of fevers, leukocytosis, wound decline or other symptoms supporting the continued need for the level of care. There were no indications of wound infections, sepsis, pneumonia or bloodstream infection on the last notes provided. For these reasons, the hospitalization services and prospective authorization and coverage for continued acute rehabilitation services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 family medicine with expertise in wound care 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 of Mavyret for eight weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret three tablets daily 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 (Kwo, et al; Zeuzem, et al). The ENDURANCE-1 trial showed that only 8 weeks of treatment is needed (Zeuzem, et al). The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewer found that while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign. Afirma Gene Expression Classifier testing utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, Afirma Gene Expression Classifier testing was likely to have been superior over other methods of evaluating this patient.Final Result: Two of the three reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla 30 mg once daily. In this case, the Health Plan has approved the patient for multiple equivalent treatments that are not contraindicated for this patient. Some of the alternatives include injectable biologic treatments that the provider says the patient cannot use due to arthritis. However, Stelara, Humira and Enbrel can be provided in-office and administered by nursing staff. Similarly, Remicade is provided through infusion and can be provided in the office setting with the provider. For these reasons, the requested Otezla 30 mg once daily is not supported as medically necessary for treatment of this 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype Dx Prostate Cancer Assay genetic testing. Findings:  Three physician reviewers found there are three major therapeutic approaches to the management of apparently localized prostate cancer. These include radical prostatectomy, radiation therapy, or active surveillance with no specific treatment given. Recommendations are made as to these options based on risk stratification. The individuals prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen and pathologic findings. Based on the records, this patient is in the favorable intermediate risk group. The treatment recommendation for this group is not as clear as in the other groups. Oncotype Dx Prostate Cancer Assay genetic testing is a 17-gene panel that may assist in predicting risk of recurrence after treatment of a patients prostate cancer. Increasingly, it is being used in localized cancer to guide initial treatment. There is sufficient support for the services at issue in this patients case. Therefore, the Oncotype Dx Prostate Cancer Assay genetic testing performed on 3/28/17 was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for office medical services (89353). The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollee who presented for infertility services. This is a situation where the patient was unable to get pregnant because she was not in a current sexual relationship and was around the age limit of natural fertility. She underwent intrauterine inseminations and in vitro fertilization (IVF) in an attempt to conceive. The contention that these were not infertility treatments but instead were preconception/prenatal care is not supported by the records or the billing, and the services were in fact provided by an infertility clinic. Furthermore, because of the patient's age, the infertility treatments she received had a very low chance of success. Her intrauterine inseminations failed, and the IVF cycle produced poor results. While it is unknown what happened with the remaining single embryo transfer, an unsuccessful outcome in this setting would not be unexpected as noted in an Up To Date review on IVF:  `The major determinant of the success of IVF is the age of the woman. Although IVF may largely overcome infertility in younger women, it does not reverse the age-dependent decline in fertility in older women, particularly those over 40 years...In IVF, the diminished success is due both to decreased ovarian responsiveness to gonadotropin stimulation, resulting in a decreased number of oocytes available for IVF, and a decreased implantation rate per embryo transferred due to poor egg quality. In addition, the risk of spontaneous abortion is significantly higher in older women.Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for treatment of the enrollees 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 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 obstetrics and gynecology 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: A patient has requested authorization and coverage for Ingrezza 40 mg capsule, (quantity of 60 per 30 days). The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients tardive dyskinesia. The submitted documentation does not support the medical necessity of the requested services. Tardive dyskinesia (TD) is a hyperkinetic movement disorder that presents usually as the result of extended use of dopamine blocking agents. The clinical elements of TD include chorea, athetosis, akathesia, dystonia, and in rare cases tremor. American Psychiatric Association guidelines include significant effort in maintaining drug regimens in schizophrenia at the lowest effective dose. There is evidence to suggest that second generation antipsychotics clozapine and quetiapine have beneficial effects on TD severity. Additionally, there are several treatments that have shown efficacy for the treatment of TD, which include clonazepam, tetrabenazine, botulinum toxin, amantadine, and levetiracetam. While Valbenazine (Ingrezza) has also demonstrated efficacy in a six-week study, long-term effectiveness and safety is unclear at this time. Given that the advantages of Ingrezza over other medications are unclear at this time, the medical necessity of Ingrezza has not been established in this case. Therefore, Ingrezza 40 mg capsule (quantity of 60 per 30 days is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 neurology 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 magnetic resonance imaging (MRI) of the brain stem, with and without dye. There is no evidence of neurological deficit on physical examination. In addition, the review of systems revealed no weakness. There was no description of head trauma related to the motor vehicle accident (MVA). There are no records indicating that the patient has been evaluated by neurology visit and there is no documentation of worsening symptoms. While MRI may be appropriate for evaluation of patients with symptoms of cervicogenic headaches to rule out intracranial etiology, the records do not support worsening symptoms or need for neurological imaging of the brain. In the absence of abnormal physical findings and progressive clinical abnormalities such as weakness on neurological examination, the requested MRI of the brain stem, with and without dye is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 diagnostic radiology 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 a lightweight wheelchair. The patients primary means of mobility is reported to be his power wheelchair. The patient should have a device that is reliable to provide his mobility needs on a daily basis.  In the event that the patients power wheelchair becomes non-operational, an equivalent, loaner power wheelchair should be provided by the durable medical equipment vendor until the primary wheelchair is fixed. If the patients power wheelchair is frequently non-operational (i.e., defective), it should be replaced by the durable medical equipment vendor with a new device that works reliably. If non-operational power wheelchairs are a consistent problem, a different vendor should be considered. A back-up manual wheelchair in anticipation of potential mechanical failure of the patients primary power wheelchair is not medically indicated. Therefore, the requested lightweight wheelchair 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.