Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene expression profiling and protein biomarkers for treatment of his prostate cancer. Findings:  Three physician reviewers found that prostate cancers natural progression covers a very broad spectrum and treatment choices are based on clinical risk stratification. Stratification utilized clinical stage of disease, baseline serum prostate specific antigen, the histologic grade group (Gleason score), and extent of involvement (including the number of biopsy cores containing cancer). The role in clinical management of molecular profiling is still under investigation. There is a lack of available prospective clinical trials evaluating their use in this setting. Active surveillance is defined as a postponement of immediate definitive therapy with curative intent treatment instituted if there is clinical evidence of disease progression.  Definitive therapy is considered radiation therapy or radical prostatectomy. Therefore, the role of molecular profiling for risk assessment is still considered investigational. Given the low risk clinical characteristics of the cancer, the utility of the gene expression profiling and protein biomarkers was not likely to have been superior to the other available treatment options for the evaluation of this enrollee.Final Result: The three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients and genotype 4 patients. Although the guidelines do recommend the Health Plans alternatives (Zepatier and Harvoni) for genotype 4, these medications have not shown effectiveness for genotype 3. Epclusa is the only AASLD/IDSA-recommended medication that is effective for both genotype 3 and 4. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, for Epclusa is medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (prothrombin G20210A (Factor II) mutation testing) for evaluation of the enrollees deep vein thrombosis.  Findings:  The 3 physician reviewers found that Data from observational studies report that the highest rates of inheritable thrombotic disorders are in patients with a family history. Testing for the presence of inherited thrombophilias is recommended. Prothrombin G20210A mutation may be suspected in an individual with familial thrombophilia, a known familial prothrombin G20210A mutation, venous thromboembolism (VTE) at an early age or unusual site, or recurrent VTE. As this patient has an extensive VTE and a mother with recurrent VTE. Thus, testing was clinically indicated to for evaluation and treatment. As such, the gene test (prothrombin G20210A (Factor II) mutation testing) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the testing at issue was 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 reviewer number one is board certified in internal medicine with sub-specialty certification in hematology and 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 hematology and 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 hematology and medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 12 physical therapy sessions for treatment of the enrollees shoulder pain. Findings:  The physician reviewer found that although PT is an appropriate initial approach for this patients shoulder diagnosis, the goal of therapy is to transition to an independent home exercise program without continued dependence on supervised therapy. The additional requested PT is not accepted as effective therapy for this patients condition. The documentation does not indicate that prior PT has resulted in significant objective increase in overall function. Thus, the 12 requested additional PT sessions do not need to be under the supervision of a therapist. The patient has had extensive prior PT and should be well versed in a home exercise program. The expected rehabilitation potential is not significant in relation to the extent and duration of PT services requested. The specialized skill of a qualified therapist is not required to establish, design and/or deliver a maintenance program to maintain the patients current condition or to prevent or slow further deterioration. Given these findings, the requested 12 PT sessions are not supported as medically necessary for treatment of this 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 neuromuscular 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 for Epclusa for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Epclusa. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Therefore, Epclusa is medically necessary for the treatment of this patient. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the AmniSure test for evaluation of the enrollees pregnancy. Findings:  2/3 of the physician reviewers found that as noted by the American College of Obstetricians and Gynecologists (ACOG), the diagnosis of ROM is traditionally made based on patient history and clinical examination including a speculum evaluation of the vagina and cervix. Typically, the patient history, with its description of leakage of fluid, can be of help to rule in or rule out the diagnosis. This coupled with a sterile speculum examination to provided direct visualization to help better evaluate vaginal/cervical secretions, to evaluate the pH of any secretions, and to perform a microscopic examination for cervical ferning complete the examination. From a review of the medical records, there is little documentation of the evaluation for this patient other than some nursing notations and laboratory results. Several tests were performed including a non-stress test which demonstrated intrauterine fetal wellbeing and a swab. AmniSure testing was performed to evaluate the complaint of leakage of fluid. The nursing documentation stated that orders were to discharge home if this testing was negative. However, there is no documentation that a sterile speculum examination was performed. There is no documentation in the chart of fluid consistent with rupture of membranes. In addition, pH testing was negative and consistent with no ROM. Given these findings, the AmniSure test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the testing at issue was 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy (25 mg once daily) for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate, which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease (Grant and Cotter). For this reason, the request for Vemlidy (25 mg once daily) is medically necessary for the treatment of this patients chronic hepatitis B. 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 Synthroid 112 mcg for treatment of the enrollees hypothyroidism status post total thyroidectomy. Findings:  The physician reviewer found that The medication of choice in hypothyroidism is levothyroxine, which is very effective and well tolerated. There are numerous preparations of levothyroxine, including Synthroid, Levoxyl and Unithroid. However, there is a lack of clinical data demonstrating that there is a difference in safety or efficacy between the various brands. Given that this patients records do not document an adequate trial of the Health Plans formulary alternatives including Levoxyl, Levo-T, or Unithroid, the requested Synthroid 112 mcg is not supported as medically necessary for treatment of this patients hypothyroidism. 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 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 orthognathic surgery (CPT 21147, CPT 21123, and CPT 30140 for treatment of this enrollee, who has been diagnosed with maxillofacial skeletal deformity. Findings:  The physician reviewer found that there is sufficient support for the requested procedure in this clinical setting. The submitted documentation supports that this patient has a maxillofacial skeletal deformity that cannot be corrected with orthodontics alone. This patient has well documented symptoms associated with her maxillofacial deformity. She reported that she has difficulty chewing and breathing. The provider noted that conservative therapies failed to correct the patients condition. Therefore, in this patients case, orthognathic surgery (CPT 21147, CPT 21123, and CPT 30140) is medically necessary for treatment of this patient. With regards to whether the requested procedure is considered reconstructive in nature, the records reveal that this patient has well documented maxillofacial skeletal deformity.  The etiology of maxillofacial skeletal deformities may be either congenital or acquired. Deformities may be evident at birth or may manifest during subsequent growth and development, creating functional, and degenerative problems. The requested orthognathic surgery will improve function and create a more normal appearance in this patients case. The orthognathic surgery will result in improved musculoskeletal and dento-osseous relationships.  Moreover, this procedure will allow improvements in mastication. For these reasons, orthognathic surgery (CPT 21147 and CPT 30140) is reconstructive in nature and not cosmetic.  Final Result: The reviewer determined that the requested procedure is medically necessary and is reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in oral facial and maxillary 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services he had received. Findings:  The physician reviewer found that the patient who presented reports that his sexual partner had gonorrhea. Physical examination revealed a lesion at the base of the penis. He underwent testing for gonorrhea and chlamydia. He was advised to undergo laboratory testing. The patient has requested reimbursement for medical services provided for bother the emergency department visit and the laboratory visit two weeks later.  The medical services provided in the emergency room were necessary for treatment of an emergency medical condition. The presence of a penile lesion is an appropriate medical condition for emergency care. In addition, screening for gonorrhea and chlamydia was also emergent. Based on the clinical documentation submitted for review, the patients symptoms support an emergency medical condition.  However the laboratory visit two weeks later had no emergent medical condition noted in the records submitted for review. The patient presented two weeks after his initial screening for laboratory testing. There is a lack of documentation supporting an emergent condition for testing on this date. Therefore, the services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services for the laboratory services.  Final Result: The reviewer determined that the enrollee received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially overturned. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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 should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  All told, Zepatier is medically necessary for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Invokana for treatment of the enrollees diabetes. Findings:  The physician reviewer found that the request for Invokana has not been established as medically necessary for treatment of the patients medical condition. Invokana and Jardiance are members of a relatively new class of diabetes medications, subtype 2 sodium-glucose transport protein (SGLT2) inhibitors. The primary mechanism of action of this group of agents involves decreasing renal glucose reabsorption, which results in enhanced urinary glucose excretion, thereby leading to reductions in plasma glucose and hemoglobin A1C concentrations. While there have been no head to head trials of the SGLT2 inhibitors, both Invokana and Jardiance appear to have similar efficacy in terms of glycemic control, weight reduction, and blood pressure lowering. In this case, the documentation does not show failure of treatment Jardiance. Given the similar efficacy of the Health Plans formulary alternative, the request for Invokana 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 internal medicine with sub-specialty 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.