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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS) for her treatment of major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation (TMS) is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. Transcranial magnetic stimulation (TMS) has been approved by the U.S. Food and Drug Administration (FDA) for use in this clinical setting. Transcranial magnetic stimulation (TMS) tends to be very well tolerated with fewer barriers than electroconvulsive therapy, which was not well tolerated in this patients case. Further, subsequent to U.S. Food and Drug Administration (FDA) clearance, the American Psychiatric Association (APA) endorsed transcranial magnetic stimulation (TMS) for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. Considering the medical records including the diagnosis of unilateral depression rather than bipolarity, endorsement from the American Psychiatric Association (APA) and the expanding peer-reviewed literature base, transcranial magnetic stimulation (TMS) is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested transcranial magnetic stimulation (TMS) is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Additionally, the guidelines recommend that patients with certain extrahepatic manifestations such as cryoglobulinemia be treated. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for sleeve gastrectomy procedure for treatment of the enrollees morbid obesity. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for sleeve gastrectomy procedure is medically necessary for treatment of the patients morbid obesity. The patient meets standard adolescent bariatric surgery guidelines, including International Pediatric Endosurgery Group (IPEG) guidelines. These criteria generally require a BMI of at least 50 or 40 with certain co-morbid conditions. In this case, the patient has a BMI that is 64 kg/m2 with sleep apnea. The patient was cleared from orthopedic and medically at full growth and also completed dietary and psychological evaluation. The patient has failed dietary efforts in the past. The risks of surgery are outweighed by the potential benefits of weight loss and treatment of morbid obesity. As such, the medical necessity for the requested procedure is indicated in this clinical setting. Final Result: The reviewer determined that the requested procedure 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 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: An enrollee has requested authorization and coverage for methadone HCL 5 mg tablets for treatment of the enrollees back and lower extremity pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. Guidelines offer very specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Methadone is an opioid analgesic recommended after a trial of a first line oral analgesic has failed. Opioids are generally not recommended as first line therapy. However, when used, clinicians should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Moreover, it is recommended that urine drug testing may be used as a tool to monitor for aberrant behavior or drug misuse. Opioids should be tapered when patient safety risks are identified. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. The guidelines recommend that providers of opiate medication document the patients response to pain medication, including the duration of symptomatic relief, functional improvements, and the level of pain relief with the medications. In this patients case, it is unclear from the documentation if there was a decrease in the level of pain from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription for morphine. Peer reviewed guidelines state that pain assessment should include current pain, the least reported pain over the period since last assessment, average pain, intensity of pain after taking the opioid, how long it takes for pain relief and how long pain relief lasts. Satisfactory response to treatment may be indicated by the patients decreased pain, increased level of function, or improved quality of life. While the medical records report chronic pain, the records do not support failure of first line opioids. The submitted records also do not show that necessary guidelines, as described in the medical literature, have been met. Therefore, congruent with peer reviewed guidelines, methadone HCL 5 mg tablets are not 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 in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dupixent for treatment of his severe atopic dermatitis. Findings: The physician reviewer has found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with chronic atopic dermatitis affecting the hands. He has tried and failed treatment with topical and oral steroids and ultraviolet light therapy. Dupixent is a U.S. Food and Drug Administration (FDA) approved injectable medication for adults, which antagonizes the IL4 alpha receptor. The treatment of atopic dermatitis involves both topical as well as systemic medications, such as cyclosporine, methotrexate, and azathioprine. Given that the patient has not tried or failed systemic agents outside of oral prednisone or had failure or intolerance of preferred systemic agents, the request for Dupixent is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3.  Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98% (Foster, et al). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Epclusa for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rimabotulinum toxin B injections for treatment of the enrollees chronic myofascial pain. Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. The patient has chronic nonmalignant pain with a diagnosis of thoracic myofascial pain. Rimabotulinum toxin B injections are not recommended for the treatment of myofascial pain. Indications for the use of rimabotulinum toxin B injections include the treatment of cervical dystonia and migraine prophylaxis and for the treatment of spasticity due to an upper motor neuron condition such as a spinal cord injury or stroke or when treating sialorrhea. Use of rimabotulinum toxin B injections in this clinical setting could potentially produce weakening of the spinal muscles and a potential worsening of the spinal condition. Based on the peer-reviewed literature and clinical documentation, rimabotulinum toxin B injections are not medically necessary for the treatment of the patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Xifaxan for treatment of the enrollees small intestinal bacterial overgrowth (SIBO). Findings:  The physician reviewer found that the patient has small intestinal bacterial overgrowth and the records note treatment and failure of two formulary alternatives. Xifaxan has been highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief. For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medical literature also indicates that the medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones.  Results are sustained for several weeks after treatment. One more recent study has corroborated this finding. A prospective trial of patients with irritable bowel syndrome and a positive breath test found that 86% responded to Xifaxan, and symptoms were reduced as well. For these reasons, the use of Xifaxan tablets is medically necessary for the treatment of this patients small intestinal bacterial overgrowth. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone for treatment of the enrollees pain. Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also state when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or more MME per day. In this case, the patient was recently taking 122 MME per day. However, in the documentation provided for review, no objective treatment goals for pain and function are noted for the requested medication and several requirements for opioid prescribing have not been documented. Further, no medical evidence based rationale is given for this patients high level of MME per day. Dose escalation is a short-term, not long-term plan, for the treatment of tolerance and no clear objective goals with this high of a dose of opioid has been established. Increases in the past appear to have been done only on the basis of the patients pain levels and not all other non-pharmacological methods such as behavior therapy of treating the patients pain have been addressed. For these reasons, the requested oxycodone is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pain management 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 reimbursement for DecisionDX-melanoma gene assay that was performed for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that the staging and prognosis of cutaneous melanoma is classically determined. As per this system, this patient would have been staged as pT3aN1 (Stage IIIa). This has an expected ten year survival of about 63%. DecisionDX is a study of 31 genes in melanoma cells. It then classifies that melanoma as either high or low risk for recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state there is interest in these newer genetic profiles, but only in the context of a clinical trial. Currently, medical studies are not clear as to how DecisionDX data compares to the 10 year data by the Balch determinations and whether it is useful in clinical practice for patients with a good prognosis, as is true in this patients case. In sum, DecisionDX-melanoma gene assay that was performed was not likely to have been more effective than the standard options available for the evaluation of this patients medical condition. Final Result: The 3 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sofosbuvir/velpatasvir (Epclusa) 400/100 mg once a day for a duration of 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Epclusa 400/100 mg once a day for a duration of 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the shingles vaccine, Zostavax for treatment of the enrollees history of shingles. Findings:  The physician reviewer found that the recommendations by the Centers for Disease and Control and Prevention (CDC) Advisory Committee for Immunization Practices endorse a single immunization for adults over the age of 60. In this case, the patient is younger than the recommended age for immunization and therefore he is not an appropriate candidate for the vaccine. In addition, prior episodes of shingles are not an indication for vaccine. Only highly immunocompromised patients with human immunodeficiency virus (HIV) infection are candidates for immunization under the age of 60, which is not the case for this patient. For the reasons provided, the request for the shingles vaccine, Zostavax is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 infectious 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.