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

Nature of Statutory Criteria/Case Summary: The patient is a male with metastatic prostate cancer to the bone requesting authorization and coverage for Xtandi. The Health Plan has denied the request as not medically necessary to treat the patients medical condition.The issue, in this case, is whether the requested medication Xtandi is medically necessary for the treatment of the patients medical condition.Patients with prostate cancer, metastatic to bone, are initially treated with androgen deprivation maneuvers, including Lupron and Casodex. The next step is usually Taxotere chemotherapy, though many would use one of the newer anti-androgen therapies, either Zytiga or Xtandi. Both of these are oral agents and appear to have roughly equivalent effectiveness. However, Zytiga must be given with prednisone, whereas Xtandi does not require that.According to either NCCN or UpToDate review, there is no real preference. One study reported on 1199 men with metastatic prostate cancer, all of whom had received Taxotere. These men were then randomized to either Xtandi or placebo. There was clear superiority to the Xtandi group both in terms of overall survival and progression-free survival. This patient has had androgen deprivation therapy and Taxotere. Thus, it is clinically beneficial to treat this patient with Xtandi, without requiring he first receives Zytiga. Therefore, Xtandi is medically necessary for the treatment of the patients medical condition, and the Health Plans decision should be overturned.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the UroLift procedure (CPT code 52441 and 52442). Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting. The UroLift procedure is a novel, minimally invasive approach to treating benign prostatic hyperplasia that lifts or holds the enlarged prostate tissue out of the way so it no longer blocks the urethra. Recent clinical trials have shown that the UroLift procedure is safe and effective in relieving lower urinary tract symptoms due to benign prostatic hyperplasia without significantly compromising sexual function. Compared with transurethral resection of the prostate and photoselective vaporization of the prostate, the UroLift procedure is a minimally invasive procedure without a requirement of general anesthesia and with a potentially shorter operative time. Based on the current literature, the UroLift procedure is standard of care for the management of patients with benign prostatic hyperplasia. Therefore, the UroLift procedure (CPT code 52441 and 52442) was likely to have been of greater benefit than other treatment options.Final Result: The reviewers determined that the services at issue were 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 1, 2 and 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Aliqopa infusions.Findings:  Three physician reviewers found that this patient was diagnosed with stage IV gastrointestinal stromal tumor. He has been treated with several prior lines of therapy, including imatinib, sunitinib, and Temodar. Aliqopa is not supported by the National Comprehensive Cancer Network guidelines in this clinical setting. The current medical literature does not support the use of this drug for gastrointestinal stromal tumor outside of a clinical trial. There is a lack of evidence indicating that the requested medication is likely to be more effective than standard therapies, such as regorafenib. Therefore, the requested Aliqopa infusions are not likely to be superior over other treatment options. Final Result: The reviewers determined that the requested medication 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient is requesting authorization and coverage of Xeljanz XR 11mg tablets. The Health Plan has denied this request as not medically necessary to treat the patients medical condition.In review of the current literature, it is found that the request for brand name Xeljanz in the treatment of ANCA-associated vasculitis has minimal support for its use in this clinical setting. In one article, the authors reported on a case study reporting successful treatment of polyarteritis nodosum (PAN) with Xeljanz. Overall, there is a paucity of medical literature to support the use of Xeljanz in the treatment of ANCA-associated vasculitis. Therefore, the Xeljanz XR 11mg 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 allergy and immunology and internal medicine with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for proton beam therapy.Findings:  Three physician reviewers found that the medical evidence has not demonstrated the superior efficacy of the services at issue over standard available therapy, photon-based intensity modulated radiation therapy (IMRT). The theoretical advantage of proton therapy is that it has a Bragg peak, resulting in decreased dose before and after the peak. This translates into a decrease in exposure of normal tissue in the low-dose to intermediate-dose range, but not in the high-dose range. Dosimetric studies have shown a benefit in bladder and rectal exposure. Thus far, this does not appear to translate into actual decreased clinical side effects. The retrospective study by Sheets and colleagues showed that gastrointestinal toxicity was actually higher with proton beam therapy, although this has not been confirmed by other studies to date. Cancer control rates are also reportedly similar between photons and protons. National Comprehensive Cancer Network guidelines noted that no clear evidence supports a benefit or decrement to proton therapy over IMRT for either treatment efficacy or long-term toxicity. Thus, proton beam therapy provided was not likely to have been more efficacious than other treatment options.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a continuous glucose monitoring system. Both the medical literature and the submitted documentation support the medical necessity of the requested CGM system. In 2016, the American Association of Clinical Endocrinologists published a consensus statement favoring the use of CGM on patients with diabetes. The statement indicates that CGM improves glycemic control and reduces hypoglycemia. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes. CGM alerts patients to impending or actual low or high glucose values and thereby facilitates prompt action and prevention of hospitalizations. Multiple studies cited in the statement have documented the superiority of CGM in improving HbA1c levels by decreasing hypoglycemia and hyperglycemia. In a study published in 2016, HbA1c levels were significantly lower in patients using CGM than those not using CGM. This is regardless of whether patients administered insulin via a pump or multiple doses of insulin.  A 2012 meta-analysis of 10 trials compared real-time continuous glucose monitoring to self-monitoring blood glucose. Four studies compared a sensor-augmented pump with multiple doses of insulin and self-monitoring blood glucose. The results of the meta-analysis supported the superiority of continuous glucose monitoring in both comparisons in terms of HgA1c reduction without increased risk of hypoglycemia.In this case, the patient is at risk for diabetes-related complications due to uncontrolled hyperglycemia. With proper use of a CGM system and the guidance of her endocrinologist, the patient will be able to make better decisions about her diabetes self-management with the insulin pump. The patient will be able to improve her HbA1c level close to goal with less risk of hypoglycemia. Therefore, the requested continuous glucose monitoring (CGM) system is medically necessary to treat the patients condition.Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine, with subspecialty certification in endocrinology, diabetes, and metabolism, 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 wireless capsule endoscopy. Both the medical literature and the submitted documentation support the medical necessity of capsule endoscopy for this patient. According to the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE), evaluation for suspected small intestinal tumors is a valid indication for capsule endoscopy. Capsule endoscopy is capable of discovering small bowel tumors missed by endoscopy and traditional radiologic imaging. CT enterography has 84.7 percent sensitivity for the detection of small bowel tumors, meaning that over 15 percent of tumors are missed. Capsule endoscopy is reported as having high sensitivity in identifying small-bowel tumors. One comparison of these modalities for the evaluation of small bowel tumors reported that the techniques complement each other, providing information that the other cannot. The other possibility, inflammatory disease, is also a valid indication for capsule endoscopy.In this case, the affected area, the jejunum, cannot be examined with a conventional endoscopy or colonoscopy, as it is not reachable with conventional endoscopes. An endoscopy or colonoscopy prior to capsule endoscopy would not be helpful. The wireless capsule endoscopy is requested to evaluate the patient for a possible small bowel polyp or tumor with a known history of small bowel (jejunal) intussusception and abdominal pain. Therefore, the requested capsule endoscopy is medically necessary to treat 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 internal medicine, with subspecialty 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 is requesting authorization and coverage for the medication Qsymia. According to the Food and Drug Administration, Qsymia is approved as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients with an initial body mass index of 30 kg/m2 or greater (obese) or 27 kg/m2 or greater (overweight) in the presence of at least one weight-related comorbid condition. The initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention, which would include a combination of diet, exercise, and behavioral modification as noted by studies. All patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with a BMI greater than 30 kg/m2 or a BMI of 27-29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, then pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction and increased physical activity to achieve weight loss goals. There are also no studies that reflect Qsymia to be more effective than generic phentermine, benzphetamine, diethylpropion, and phendimetrazine. Therefore, the requested medication, Qsymia, is not medically necessary to treat 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 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 patient is a male who has requested reimbursement for residential treatment center (RTC) services. The Health Plan denied the request as not medically necessary.The American Psychiatric Association treatment guidelines for substance use disorders recommend that residential treatment or similar care, higher than outpatient, is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, lack sufficient social and vocational skills and drug-free social supports to maintain abstinence in an outpatient setting.Patients require safe and stable living environments in order to develop their recovery skills, thus qualifying for ASAM (American Society of Addiction Medicine) Level III treatment at least i.e., similar to what the patient received at the facility.In this case, the patient had no home during the dates at issue. Despite multiple attempts at lower levels of care, he continued to use risky and life-threatening substances. He did not attend to his basic personal activities of daily living. Given the severity of his illness, RTC services were in accordance with generally accepted standards of medical practice, clinically appropriate for his illness and medically necessary. Final Result: The reviewer determined that the requested services were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for one percent testosterone cream compound. Studies have concluded that evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy. Studies also concluded that customized compounded hormones pose additional risks, as these preparations have variable purity and potency and lack efficacy and safety data. Because of inability and bioactivity, both under dosage and over dosage are possible with compounded bioidentical hormones. Studies haave noted that compounded drugs are not regulated by the U.S. Food and Drug Administration (FDA); they have the same risks as FDA-approved hormone therapies, and they also may have additional risks because of the way they are made. The Committee observed that over a six-month period, the FDA performed repeat analytic testing of 29 internet-ordered samples, including estradiol and progesterone from 12 compounding pharmacies. Although none of the preparations failed identity testing, 10 of the 29 preparations (34 percent) failed one or more standard quality tests performed, including potency testing. In contrast, the analytical testing failure rate for drug therapies approved by the FDA is less than two percent.Although testosterone can be helpful in the prevention of osteoporosis, it is not a first-line therapy, as the unknown risks do not outweigh the benefits. There are many other therapies that can be utilized for osteoporosis prevention, such as weight-bearing and core exercises, avoiding certain medications and foods, avoiding excessive drinking and smoking, a healthy amount of calcium in the diet, vitamin D supplementation, and various FDA approved therapies such as bisphosphonates, Evista, and Prolia.In this case, the patients menopause complaints are centered around her desire to use testosterone hormone replacement for improvement of energy and libido. It is also claimed that her bone density improvement (osteoporosis and hip fracture prevention) is directly related to testosterone use. Despite the success the patient may be experiencing with menopausal symptoms, testosterone hormone replacement is not recommended, especially as first-line therapy. Based upon the submitted clinical notes and current peer-reviewed literature, the requested 1% testosterone cream compound 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 obstetrics and gynecology 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 a patient is requesting authorization and coverage of residential treatment center services. The Health Plan had denied the services as not medically necessary to treat the enrollees behavioral health condition. At issue in this case is whether the requested RTC services were medically necessary for the treatment of the patients behavioral health condition.Findings:  The physician reviewer found that the American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, treaters score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. The patient presented with a composite score of 17. For a CALOCUS composite score of 17, the recommended level of care is high-intensity outpatient therapy. Therefore, the RTC services were not medically necessary for this patient.Final Result: The reviewer determined that the services at issue were 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 psychiatry with subspecialty 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.