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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for the medication Mavyret 100mg-40mg three times daily for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 3 patients should be treated with Mavyret 100-40 mg (three tables daily) for eight weeks. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg for eight weeks is medically necessary for this patient.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 Internal Medicine, with a subspecialty certificate 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 authorization and coverage for the medication Mavyret for eight weeks.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-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 Mavyret 100/40 mg, three tablets daily, for 8 weeks. Zeuzem and colleagues reported that the ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret for eight weeks is medically necessary for this patient.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 Internal Medicine, with a subspecialty certificate 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: The parent of an enrollee has requested reimbursement for immunoglobulin G (IgG) testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Food-specific IgG level testing does not predict true food hypersensitivity and may actually be a marker of earlier development of food tolerance. Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood immunoglobulin E (IgE) levels for foods and skin testing. IgE immunoassays are in vitro assays which are used to identify food-specific IgE in the serum. Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95 percent. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. In conclusion, the IgG testing was not likely to be more effective than other available methods of evaluating this patient. Final Result: The reviewers determined that found 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: Physician reviewers 1, 2 and 3 are board certified in allergy and immunology 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 reimbursement for brain Magnetic Resonance Angiography (MRA). The submitted documentation does not support the medical necessity of the brain Magnetic Resonance Angiography (MRA) in issue. Colleagues, through a process of literature review and consensus, have recommended that neuroimaging is not indicated in migraine with a normal neurologic examination and no significant change in symptoms. This includes CT, MRI, and MRA. There are guidelines from the American Academy of Neurology which support this guideline. MR angiography is used when there is a concern for a vascular lesion such as an aneurysm or arteriovenous malformation and is not typically ordered for primary headache disorders. The records provided give no rationale for obtaining neuroimaging, as the patients migraines appear to be long standing and well controlled with Elavil. This patient fails to provide any medical evidence for needing brain Magnetic Resonance Angiography (MRA). Therefore, the services in issue were not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the services in 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 neurology 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 authorization and coverage for Euflexxa injections. Findings:  Two of the three physician reviewers found the records note the diagnosis of left knee osteoarthritis. It is unclear how this diagnosis has been made, as there are no imaging reports or operative reports in the submitted records which document the presence of left knee osteoarthritis.  He has been managed with an appropriate course of conservative management and has received viscosupplementation treatments with reported good response lasting four to five months. There is no documentation of a failed trial of corticosteroid injections.  Repeat series of injections are recommended by most guidelines only if there is documented significant improvement in symptoms for six months or more, and symptoms recur. This is not supported by the documentation. Therefore, Euflexxa injections are not likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 Hyaluronan (Euflexxa) injections in the left knee. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. There is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The reviewed medical literature also includes a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. This review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Hyaluronan (Euflexxa) injections in the left knee are medically necessary for the treatment of this patient.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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis with joint involvement that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intensity modulated radiation therapy (IMRT). Based on the review of the available data, that the proposed treatment of concurrent chemoradiation with IMRT to 60 Gy is within the current standard of care, and is likely to be beneficial than standard three-dimensional (3D) conformal radiotherapy. The typical histology for rectal carcinoma is adenocarcinoma, and not squamous cell carcinoma, as in the case of this patient. Treatment for squamous cell carcinoma tends to include a combination of the treatment regimens for squamous cell carcinoma of the anus and adenocarcinoma of the rectum. Thus, neoadjuvant chemoradiation using 60 Gy with Mitomycin C has been recommended, with surgery to follow. This is approach is supported by published literature. This aggressive approach involves treating to 60 Gy, yet the bowel has a tolerance of 50 Gy. Thus, the use of IMRT to spare exposure to the bowel is appropriate. Accordingly, the requested IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested IMRT is 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 IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for pediatric occupational therapy services within 15 minutes of the enrollees residence by car.   Juvenile idiopathic arthritis is a chronic rheumatologic disease in childhood that presents with peripheral arthritis. Treatment is aimed at elimination of active disease, normalization of joint function, preservation of normal growth, and prevention of long-term joint damage. Medications include corticosteroids, non-steroidal anti-inflammatory agents, anti-rheumatic drugs, and biologic agents. Hand and wrist related symptoms are relatively common in children with juvenile idiopathic arthritis. Unless treated, these symptoms can significantly limit participation in both leisure and school activities. A combination of pharmacologic and non-pharmacologic therapies is essential in preventing functional limitations. This patient has significant joint pain limiting his ability to travel distances without pain and/or frequent breaks. Thus, it is medically necessary and appropriate to locate therapists within a tolerable distance. The family has identified a qualified provider of occupational therapy within a 15-minute car ride, within the range of tolerability for this patient. Therefore, pediatric occupational therapy services within 15 minutes of the patients residence by car are medically necessary for the treatment of this patient.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 pediatrics 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 Mavyret. 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 non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Mavyret. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 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 acute inpatient rehabilitation care. Multidisciplinary rehabilitation plays a role in the management of pain associated with spine conditions and following spine surgery in general. General goals would include pain management and optimizing function towards independence. In the present case, the enrollee sustained her original injury and underwent multilevel vertebroplasties. She has had chronic back pains and limited mobility since that time. The patient sustained another injury and has been undergoing rehabilitation but has been making very slow progress. She and her family are requesting care at the acute inpatient rehabilitation level of care. A psychiatric consultation was obtained, which indicated that the patient was making very slow progress overall and opined that she was not a candidate for acute inpatient rehabilitation. Given the patients limited baseline functional status and the slow rate of progress with rehabilitation overall, the patient would not be expected to tolerate or marginally benefit from acute inpatient rehabilitation over rehabilitation provided in a less intensive setting.  Her principal rehabilitative issues are chronic in nature and her recovery is expected to be protracted. Acute inpatient rehabilitation at this time is not expected to favorably impact her clinical course or outcomes. Therefore, the requested acute inpatient rehabilitation care is not medically necessary for the treatment of this patient. 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 spinal cord injury 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 Oncotype DX Prostate Cancer Assay. Findings:  Two of the three physician reviewers found that there are three major therapeutic approaches to the management of apparently localized prostate cancer. These include surgical prostatectomy, forms of radiation therapy, or active surveillance, with no specific cancer treatment. Recommendations are made as to these options based on risk stratification, meaning an estimate of the risk for the future development of recurrence and progression of cancer. The patients prostate cancer is evaluated with a combination of clinical features, prostate-specific antigen (PSA) level, and pathologic features. Based on this categorization, this patient would be placed in the intermediate risk category. A further refinement of prognostication is the use of gene panels, such as Oncotype DX Prostate Cancer Assay. This is a 17-gene panel that may assist in predicting recurrence after treatment of prostate cancer. Increasingly, it is being used in localized prostate cancer to guide treatment decisions, particularly in those patients who by risk stratification fall into the low to intermediate risk categories, such as this patient. Therefore, Oncotype DX Prostate Cancer Assay was likely to have been of greater benefit than other methods of evaluating this patient. 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 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.