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 Euflexxa injection for the left knee. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees left knee osteoarthritis. Findings:  The physician reviewer found that evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and more effective than corticosteroid injections. In this case, the patient presents with chronic left knee pain and a diagnosis of primary unilateral osteoarthritis of the left knee. She has failed other conservative treatments, including corticosteroid injection. She was treated with a series of Euflexxa injections with significant pain relief and ability to reduce her use of anti-inflammatory medications. Repeat viscosupplementation injections have been found to be safe and effective and allow for delay of knee replacement surgery. Therefore, the request for Euflexxa injections for the left knee are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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 advanced lipoprotein testing for evaluation of the enrollees coronary artery disease. Findings:  The physician reviewers found that based on the records provided the patient presents with increased coronary risk and documented coronary ischemia on stress testing. In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For the reasons provided, the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three 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. Physician reviewer number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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 Synvisc 16 mg/2 ml injections for treatment of the enrollees knee pain. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Nationally recognized evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as an option for patients with osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. Additionally, the literature indicates that if there is significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. There is no maximum amount of injections established by high quality scientific evidence. The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. The medical literature indicates that viscosupplementation is safe and effective. Additionally, these injections allow for delay of total knee replacement and are more effective than corticosteroid injections. In this patients case, the patient has been diagnosed with osteoarthritis of the left knee. He reports severe pain with functional limitation in work activities. Prior viscosupplementation injection have provided good pain reduction and improvement in function for six to eight months. This patient had failed to adequately respond to other conservative treatment including medications, physical therapy and corticosteroid injection. Therefore, the requested Synvisc 16 mg/2 ml injections are medically necessary for treatment of the patients medical condition. Final Result: The reviewer 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: 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: The request for daratumumab (Darzalex) infusion is not medically necessary for treatment of the patients medical condition. Daratumumab is U.S. Food and Drug Administration approved for treatment of multiple myeloma in combination with dexamethasone and either lenalidomide or bortezomib in patients who have received at least one prior therapy; treatment of multiple myeloma in combination with dexamethasone and pomalidomide in patients who have received at least two prior therapies, including lenalidomide and a proteasome inhibitor; and treatment of multiple myeloma as monotherapy in patients who have received at least three prior lines of therapy, including a proteasome inhibitor and an immunomodulatory agent or who are double refractory to a proteasome inhibitor and an immunomodulatory agent. The National Comprehensive Cancer Network (NCCN) guidelines also supports this approach. Daratumumab as a single agent is reserved for patients with at least three prior lines of therapy as studies comparing to other agents is limited and monotherapy has only been studied on heavily pretreated patients. The records indicate that this patient has not yet tried drugs or combinations of drugs that may be more efficacious. In addition, the use of daratumumab can interfere with type and cross match for blood transfusions and monitoring for disease recurrence. For the reasons provided, treatment with daratumumab 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 medical oncology and hematology 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 requested authorization and coverage for magnetic resonance imaging (MRI) of the prostate for evaluation of the enrollees elevated prostate specific antigen (PSA) and obstructive voiding symptoms. Findings:  The physician reviewer found that The American Urological Association (AUA) and Society of Abdominal Radiology (SAR) guidelines state that while there is interest in the utility of MRI of the prostate for directed biopsies, the use of magnetic resonance imaging (MRI) of the prostate without a prior negative or equivocal biopsy and subsequent elevated suspicion of prostate cancer is not recommended or supported by the current medical literature. This patients records do not document that he has undergone evaluation with an ultrasound guided biopsy of the prostate. As such, the patient does not meet the AUA and SAR criteria for multiphase MRI of the prostate. Thus, the requested MRI of the prostate is not medically necessary for evaluation of this patients enlarged prostate, poor urinary stream and elevated prostate specific antigen (PSA). Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 records provided for review document that this patient has had improvement in her symptoms with fiber supplementation and two providers have recommended a trial of biofeedback, which may also be beneficial. The patient does not have circumferential full thickness prolapse, which is the most common presentation with rectal prolapse. According to the American Society of Colon and Rectal Surgeons, surgical options are reserved for patients with full thickness rectal prolapse (Bordeianou, et al). Moreover, not all of the patients symptoms are likely to improve with surgery or attributable to the anatomic finding of 2 cm anterior rectal prolapse (Pescatori, et al). All told, the requested rectal prolapse surgery is not supported as medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in colon and rectal 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the aortopathy/connective tissue disorders multi-gene panel genetic testing for evaluation of the enrollees joint hypermobility and subsequent joint pain. Findings:  The physician reviewers found that Hypermobile Ehlers-Danlos syndrome is diagnosed clinically based on findings of generalized joint hypermobility and soft skin without significant elasticity or fragility. These features distinguish this syndrome from classical Ehlers-Danlos syndrome, in which the skin is very elastic and fragile. Vascular Ehlers-Danlos syndrome is characterized by specific facial and skin features not described in this patient and high risk of arterial or organ rupture. The genetic testing provided in this case evaluates the genes associated with these conditions, as well as the genes associated with other inherited connective tissue disorders, such as Marfan syndrome and Loeys-Dietz syndrome, though the patient is not described as having features concerning for these. The testing also includes genes associated with non-syndromic thoracic aortic aneurysm and dissection, which this patient does not have. All told, the aortopathy/connective tissue disorders multi-gene panel genetic testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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 reviewers number one, two, and three are board certified in in internal medicine with sub-specialty certification in rheumatology 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: In cases such as this an evidence based instrument such as the Child and Adolescent Level of Care Utilization System (CALOCUS) is useful in determining necessary level of care for children, to insure their level of care meets their individual needs at the least restrictive setting possible. The patient had some risk of harm (score 2) due to the patients history of a suicidal ideation that was noted in the progress notes. The patient demonstrated moderate functional status (score 3) as the patient has had deterioration and expected level of functioning in relationships with peers, adults and family. The patient has minor co-morbidities (score 2) as he was noted to have cannabis use in remission and does not have active serious medical problems. The patients recovery environment was mildly stressful (score 2) as the patient has issues with family relationships but has a stable housing situation. The patients recovery environment is supportive (score 2) as his family actively participates in treatment. The patient has demonstrated equivocal response to treatment (score 3) due to recent lack of progress in his IOP. The patient has been obstructive in treatment (score 3) as he inconsistently participates in therapy. The patients parents have been constructive (score 2) as they work actively and constructively with providers. This gives the patient presentation a composite score of 19 which correlates with IOP services. In summary, the IOP services were and are medically necessary for treatment of this patients behavioral health issues. Fulfills requirements of (1374.33)(h)(1)(H) and (K)Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Fulfills requirement of 1374.33(h)(1)(I)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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Monurol three (3) grams once per week. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees medical condition.  Review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. Researchers studied the long-term administration of fosfomycin for the prevention of recurrent lower urinary tract infections. The results of the study support fosfomycin trometamol as highly effective in the prophylaxis of urinary tract infection recurrences with beneficial effect in the six months of follow-up. In addition, the report by researchers found that fosfomycin is safe and effective for use in patients with complex comorbidities. In this case, the patient has contraindication of several commonly used antibiotics and she is at high risk for complications of infection. For the reasons provided, the request for Monurol three (3) grams once per week 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 internal medicine with sub-specialty certification in nephrology 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 DecisionDx-Melanoma gene testing for evaluation of the enrollees cutaneous melanoma. Findings:  The 3 physician reviewers found that The National Comprehensive Cancer Network guidelines indicate that genetic testing such as the DecisionDx-Melanoma assay should not be used outside of a clinical trial setting. The use of DecisionDx-Melanoma testing is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or outcome of the patients melanoma. All told, the DecisionDx-Melanoma gene testing performed was not 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 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 3a. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic treatment naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate of 98%. The AASLD/IDSA guidelines do not recommend NS5A resistance testing before use of Epclusa. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed at this time, and the requested treatment with Epclusa 400-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The physician 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 physician 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.