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 gastric bypass for treatment of the enrollees obesity. Findings:  The physician reviewer found that this patient meets all of the standard nationally accepted criteria for bariatric surgery including the guidelines from the American Society for Metabolic and Bariatric Surgery. The records document morbid obesity with a BMI of 39 and at least one serious obesity co-morbid condition with obstructive sleep apnea. In addition, the patient completed a thorough multidisciplinary evaluation that did not reveal any obvious dietary or behavioral barriers to surgery and also documented completion of supervised dietary efforts for over six months. Final Result: The reviewer determined that the requested surgery 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 with sub-specialty certification in bariatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral Orthovisc injections series at the frequency of once per week for three consecutive weeks. Findings:  The physician reviewer found that the evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The study concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. The patient has undergone two prior viscosupplementation series with marked pain reduction, improvement in functional ability and ability to avoid surgery. The patient has failed to respond to other conservative treatment including anti-inflammatory medications, activity modification, and corticosteroid injections. Therefore, the requested bilateral Orthovisc injections series at the frequency of once per week for three consecutive weeks are medically necessary for treatment of the patients bilateral knee osteoarthritis. Final Result: The reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genotype testing. Findings:  Three physician reviewers found that, in general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may well become a valuable tool in the treatment options for those plagued with psychiatric illness. However, despite its promise, genotype tests is not currently superior to the existing mainstream clinical application.  The medical literature does not recommend genetic testing for cases involving routine medication management. Moreover, the American Psychiatric Association (APA) did not endorse such testing in a recent official statement or its most current clinical practice guidelines. Further, the APA recently acknowledged the potential value of genetic testing but stopped well short of endorsement, noting the following, More research is needed before genetic testing can be recommended for routine clinical use. Additionally, a thorough search of the current literature failed to return well-designed or adequately powered studies illustrating consistent and reproducible results that provide clinically useful information pertaining to genotype testing and its relationship to specific pharmacologic interventions. This is likely due at least in part to the fact that many other factors are involved in drug metabolism besides a patients genetic makeup, such as smoking status, diet, concurrent treatment therapies, and other environmental and physiological factors. The current lack of such exploratory and confirmatory studies is another factor that renders genotype testing experimental/investigational for the evaluation and treatment of anxiety and mood disorders. Finally, it is unclear if this patient had exhausted standard treatments available to treat her condition. In sum, considering the relevant peer-reviewed literature and current practice standards, the disputed genotype test performed was not likely to have been more beneficial than any available standard therapy for the evaluation of this patient. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to have been 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xeljanz XR for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the American College of Rheumatology (ACR) guidelines for treatment of RA recommend methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in those who have failed MTX alone. In regards to the use of Xeljanz (tofacitinib) for treatment of RA, the guidelines state, there are potential longer-term safety concerns related to tofacitinib that need more study, partly related to the shorter experience using tofacitinib.  The guidelines recommend TNFi with or without MTX over tofacitinib as there may be some potential longer term safety concerns related to tofacitinib. More studies of tofacitinib were recommended. In this patients case, the patient has failed MTX, sulfasalazine and prednisone.  However, she has not failed a second TNFi or a non-TNF biologic agent as recommended by the guidelines.  During the patients most recent evaluation, no tender joints were reported on examination. Therefore, Xeljanz XR 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 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: An enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 4. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 4 patients should be treated with Harvoni for 12 weeks. This recommendation is based on the SYNERGY trial for Harvoni, which showed a 100% cure rate. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy.  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 facial feminization surgeries (repair brow ptosis; reduction forehead contour and graft; reduction of facial bones) for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that based on the entirety of the medical documentation provided for this review, the requested services are not medically necessary. The medical literature supports facial feminization surgery which can include forehead remodeling, rhinoplasty, thyroid chondroplasty, and voice alteration procedures for treatment of gender dysphoria. Although this patient has documented gender dysphoria, the requested services are based on aesthetic goals. Based upon the documentation provided, there appears to be slight brow ptosis, mild frontal bone projection and a relatively wide appearing face.  However, these findings are relatively gender neutral. Therefore, this is not atypical for a female appearance. There is a lack of evidence to indicate a clearly masculine appearance of the brows, forehead and facial bones. Based on the submitted documentation, the patient has findings of the brows, forehead and facial bones which are more consistent with a relatively normal appearance for a female. Therefore, the medical necessity of the requested services for treatment of the patients gender dysphoria has not been established. With regard to whether the requested services are considered reconstructive in nature, the first criterion that must be met is whether the patients facial features represent an abnormal structure. There is a wide spectrum of facial appearances that can be consistent with typical female appearances. This patient has a normal facial appearance that is not gender specific for the brows, forehead and facial bones. The patients brows, forehead and facial bones appear within the norm for a typical female. As such, the patients facial features are not considered abnormal for a person of the female gender. All told, the requested facial feminization surgeries (repair brow ptosis; reduction forehead contour and graft; reduction of facial bones) are not reconstructive in nature for the treatment of this patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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 Sovaldi for 12 weeks 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 regardless of fibrosis stage.  Per the guidelines, for treatment-naive, genotype 2 patients, therapy is recommended with Sovaldi/Daklinza or Epclusa.  Sovaldi and ribavirin are no longer recommended.  The guidelines cite data showing that delay in treatment may result in decreased survival.   Final Result: The reviewers determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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 reimbursement and prospective authorization and coverage for transcranial magnetic stimulation (TMS) treatments for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that while there is support in the medical literature endorsing the efficacy of TMS for the acute phase treatment of major depressive disorder, there is a lack of evidence based literature for its use as maintenance therapy. An open label prospective study recommended that further studies with larger cohorts would be helpful in determining the long term efficacy of TMS maintenance therapy. In another cited literature, they found that the evidence available on the use of TMS as maintenance therapy remain underdeveloped. In this patients case, she showed a positive response to the initial TMS treatments. The patient reported depression and indicated that the week prior was one of the best she had had in years. By the end of the year, the patient had received 70 TMS sessions. The patients provider had noted that the TMS treatments would eventually be tapered off and discontinued. The records are unclear as to why TMS treatments after the initial 35 sessions were continued. As such, the submitted records do not demonstrate a clear rationale or benefit of the TMS sessions for treatment this patient.  Moreover, there is a lack of support in the literature to indicate the efficacy of TMS as maintenance. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: An enrollee has requested authorization and coverage for T6, T7, and T8 thoracic radiofrequency ablation. Findings:  Three physician reviewers found that the records provided for review document physical findings on exam consistent with facet mediated pain. The provider noted diagnostic medial branch blocks resulted in greater than 75% improvement in pain for the duration of the anesthetic in support of radiofrequency ablation of the facet joint. Studies reported durable effect of radiofrequency ablation for lumbar facet syndrome at long-term follow-up, as measured by improvement in function, pain, and analgesic use. Studies noted good evidence for the use of conventional radiofrequency ablation, and fair to good evidence for lumbar facet joint nerve blocks for the treatment of chronic lumbar facet joint pain resulting in short- and long-term pain relief and functional improvement. Accordingly, the requested T6, T7, and T8 thoracic radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the requested services are 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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: A 39-year-old female enrollee has requested authorization and coverage for Epclusa tablets 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus 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, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer examination. Findings:  Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  In this case, the patient has breasts that have been described as heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. In addition, the ability to separate out the overlapping structures enables the possibility of demonstrating or excluding an otherwise occult tumor. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2, and 3 are board certified in diagnostic radiology and are 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 transforaminal epidural steroid injections for treatment of the enrollee's chronic low back pain. Findings:  The physician reviewer found that evidence based medical guidelines support the use of epidural steroid injections as a possible option for the treatment of radicular pain defined as pain in dermatomal distribution with corroborative findings of radiculopathy. On the other hand, medical evidence suggests that epidural corticosteroid injections are not effective for spinal stenosis or non-radicular back pain. The criteria for epidural steroid injections include radiculopathy documented by physical examination and corroborated by imaging studies and/or electrodiagnostic studies. Furthermore, patients should have been initially unresponsive to conservative treatment. In this patients case, the records do not support a diagnosis of radicular pain. Instead, this patient has a history of chronic non-radicular low back pain. Physical examination findings did not evidence a focal neurologic deficit. Imaging showed degenerative disc disease at L4/5 and L5/S1 without evidence of a specific nerve root compromise. Prior bilateral L4/5 and L5/S1 epidural steroid injections were provided four times over the prior six months. Her pain relief lasted between two to three weeks. There was no documentation of a functional response or reduction in pain medication. Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has not been submitted. Given the absence of signs/symptoms or clinical findings of radiculopathy, the use of epidural steroid injections is not supported by evidence based medical guidelines or literature. Additionally, there is no evidence of at least 50 to 70 percent pain relief with multiple prior epidural steroid injections for at least six to eight weeks to support repeated epidural injections. 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 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.