Persius/hicric huggingface dataset:
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 Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily. Findings:  The physician reviewer found that the request for Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient meets criteria for GH deficiency and GH therapy is clinically indicated. However, there is a lack of documentation demonstrating that the patient is allergic to the Health Plans preferred brand or that he was tried alternative brands that resulted in an allergic reaction. Thus, the medical necessity for brand name of Genotropin 0.8 mg/0.25 mL syringe, alternating 0.8 md sq. daily has not been established as 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for high-intensity focused ultrasound (HIFU) for treatment of the enrollees prostate cancer. Findings:  Three physician reviewers found that HIFU consists of focused ultrasound waves, emitted from a transducer, that cause tissue damage by mechanical and thermal effects as well as by cavitation. The goal of HIFU is to heat malignant tissues so that they are destroyed by coagulative necrosis.  HIFU has been increasingly been used for treatment of localized prostate cancer within the last decade. It has the theoretical potential of decreasing gastrointestinal, genitourinary and sexual toxicity. Potential candidates are patients with low-risk to moderate-risk prostate cancer. The available literature mainly consists of prospective case series and retrospective studies showing short to intermediate term outcomes for localized prostate cancer. However, there is a lack of controlled trials available for analysis, and a paucity of long-term survival data is available. The National Comprehensive Cancer Network guidelines note other emerging local therapies, such as high-intensity focused ultrasound (HIFU) and vascular-targeted photodynamic (VTP) also warrant further study. American Urological Association/American Society for Radiation Oncology/Society of Urologic Oncology guidelines note clinicians should inform low-risk prostate cancer patients who are considering focal therapy or high-intensity focused ultrasound (HIFU) that these interventions are not standard care options because comparative outcome evidence is lacking. 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: 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patients parent has requested reimbursement for the residential treatment services provided. Findings:  The physician reviewer found that the records indicate that the patient was cooperative with staff and her activities of daily living were intact. The medical records do not support active suicidal ideation or psychosis during the disputed period. The documentation indicates that the patient was functioning well and expressed motivation to understand her substance use and maintain her sobriety. She had no active serious medical problems and no symptoms of substance withdrawal. She appeared to be insightful into her need for treatment despite initially not wanting to be at the residential treatment center. According to the American Society of Addiction Medicine (ASAM) criteria, the residential treatment services provided were not medically necessary. Overall, the patients presentation suggests risk rating scores in the range of zero to two, which is consistent with intensive outpatient services (IOP) of nine or more hours of service per week. Further, a study noted that IOPs are an important part of the continuum of care for alcohol and drug use disorders. They are as effective as inpatient treatment for most individuals seeking care. Thus, the patient could have been treated in a less restrictive setting safely and effectively as she did not have severe symptoms that necessitated 24-hour residential care. Accordingly, the residential treatment services provided were not medically necessary for treatment of this patients behavioral health condition. 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the Botox injections for treatment of the enrollees intractable chronic migraine without aura. Findings:  Two physician reviewers found that Botox has been established as safe and effective for chronic migraine, and is U.S. Food and Drug Administration (FDA) approved for this condition. No other preventives are FDA approved for treatment of chronic migraine. While there is evidence of benefit with topiramate, direct comparison favors Botox, in terms of treatment adherence, side effects, and overall benefit. Per research, Botox and topiramate demonstrated similar efficacy in the prophylactic treatment of chronic migraine while patients treated with Botox had fewer adverse events. Final Result: The reviewers determined that the service at issue was 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 is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. Reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus. 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%. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that Residential treatment center services provided on 2/7/17 were medically necessary for treatment of the patients behavioral health condition, but not thereafter. The patients blood pressure was low, however there are no medical records addressing this issue. A nursing note documents that the patient was offered Gatorade for dehydration and to raise blood pressure. Other than that episode, the patients vital signs on the remaining days were stable. According to the documentation submitted for review, the patient was not a danger to self or others. The patient was cognitively intact and able to care for self. There were no emotional, behavioral, cognitive, or impulsive symptoms that would support the residential treatment level of care  forward. The patient was psychiatrically stable. As such, the residential treatment center services provided on the date of dispute were medically necessary, however as of the next day, the patient could have been treated at a lower level of care.  Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 reimbursement for gene panel testing. Findings:  The physician reviewer found that this patient meets National Comprehensive Cancer Network (NCCN) guidelines for genetic testing based on a first degree relative. The patients mother was diagnosed with  breast cancer under the age of 50. Additionally, the patient also had other close relatives who were diagnosed cancer.  The patients paternal grandfather was diagnosed with male breast cancer and a paternal aunt was diagnosed with gastric cancer. Both sides of her family have a high likelihood to have passed on a gene that would make this patient susceptible to breast and ovarian cancer and possibly other cancers. The recent introduction of multigene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at risk patients and their families. Based on next generation sequencing technology, these tests simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes. When more than one gene can explain an inherited cancer syndrome, then multigene testing may be more effective. All told, the panel gene testing was likely to have been more beneficial than the other standard options available for the evaluation of 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 & 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee 0.45 mg/20 mg tablets. Findings:  The physician reviewer found that the request for Duavee 0.45 mg/20 mg tablets is medically necessary for treatment of the patients medical condition. Estrogen only regimens such as estradiol tablets and Estring are not medically appropriate in this clinical setting. In addition, Premarin vaginal cream is indicated only for local vaginal symptoms related to menopause. Systemic hormonal medications are the standard of care for treatment of vasomotor symptoms. In this case, the patient still has her uterus and endometrial protection provided by a combination estrogen/progesterone regimen is appropriate. Moreover, this patient has been treated with Duavee for several years and has been and doing well. The continued use of Duavee is medically necessary for treatment of the patients difficult to treat medical condition. For the reasons provided, the requested medication is medically necessary for treatment of the patients medical condition.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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a heart valve replacement using a catheter (transcatheter valve repair) for treatment of the enrollees mitral regurgitation and congestive heart failure (CHF). Findings:  Three physician reviewers found that this patient needs a mitral valve intervention considering her age and decline in her ventricular function. Mitral valve intervention would be expected to have the greatest long-term benefit before ventricular function further deteriorates. However, there is a lack of data demonstrating that the MitraClip is likely to provide a long-term advantage over a standard open heart mitral valve procedure with either repair or valve replacement. The MitraClip is U.S. Food and Drug Administration (FDA) approved for prohibitive risk patients. However, this patient, despite her comorbid health conditions, is not high risk with respect to standard open mitral valve procedures. Thus, the requested heart valve replacement using a catheter (transcatheter valve repair) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service 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: Reviewers 1 and 2 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing.  Reviewer 3 is board certified in thoracic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Butrans patch. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested medication. The patient has Crohns disease. The use of chronic opiate agonists in Crohns disease may cause narcotic bowel syndrome, resulting in a worsening of the pain. The use of opiates in Crohns patients has also been associated with an increased risk of infections. Because of these two issues, chronic oral opiate therapy is controversial. However, Butrans patch has not been shown to have these issues at this time. All told, the requested Butrans patch is medically necessary for the treatment of this patient. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc/Synvisc One for treatment of the enrollees bilateral knee osteoarthritis.  Findings:  The physician reviewer found that the use of hyaluronan is not consistently supported by evidence based literature. There have been carefully conducted double-blinded studies, which do not report any clinical effect from hyaluronan injection. There is also a low but present risk of iatrogenic infection being introduced into the joint during the process of injection. A recent meta-analysis of the efficacy of viscosupplementation reviewed a total of 89 trials involving 12,667 adults. The authors of this research reported that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit with an increased risk of serious adverse effects. Several studies evaluating repeated treatment protocols document adverse events including inflammatory changes within the knee joint in some cases requiring arthrocentesis after multiple injections. The risk of sensitization is expected to increase after repeated exposure to an antigenic substance. By reason of the limited or no benefit demonstrated in well-designed, double-blinded studies and the documented incidence of acute local reactions, the requested Synvisc/Synvisc One is not supported as medically necessary for treatment of this 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for morphine sulfate. Findings:  The physician reviewer found that based on current medical literature and in consideration of the presented clinical records, morphine sulfate is not medically necessary for treatment of the patients medical condition. The requested medication is excessive in light of the patients condition and in addition to the medication regimen. The medical records have shown the patient to have chronic nonmalignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. Based on a study , there are well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by another study, which states that, Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic lower back pain. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic pain Furthermore, these therapies work best in a multidisciplinary rehabilitation context. There are a variety of anticonvulsants and antidepressants that are considered adjunctive to pain management therapy. If there is poor response to conservative therapy then surgery should be considered. Recent studies have shown that high dose opioids are associated with a high risk of dependence and tolerance. Long term opiates are more likely to cause adverse outcomes including adrenal suppression and dependence. Based on current medical literature and in consideration of the presented clinical records, morphine sulfate is 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 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.