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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a hysterectomy with anterior and posterior repair for treatment of the enrollees pelvic pain. Findings:  The physician reviewer found that the records indicate that this patient has a significant history of chronic pelvic pain. Pelvic ultrasound imaging was inconclusive for adenomyosis. Adenomyosis is characterized by uterine enlargement caused by ectopic rests of endometrium located deep within the myometrium. These rests may be scattered throughout the myometrium, creating diffuse adenomyosis, or they may form a circumscribed nodular focal collection causing focal adenomyosis. Although either form may be suspected clinically, the diagnosis is usually based on histologic findings in surgical specimens. Accordingly, reported incidences in hysterectomy specimens vary depending on the histologic criteria as well as the degree of sectioning, but range from 20 to 60%. Approximately one third of women with adenomyosis have symptoms. The severity correlates with increasing number of ectopic foci and extent of invasion. Menorrhagia and dysmenorrhea are common. Menorrhagia possibly results from increased and abnormal vascularization of the endometrial lining. Dysmenorrhea is thought to be caused by increased prostaglandin production found in adenomyotic tissues compared with that in normal myometrium. Perhaps 10% of women with adenomyosis complain of dyspareunia. This patients records do not document menorrhagia and/or dysmenorrhea. Her pain was documented as ending with the onset of menses. A follow-up pelvic ultrasound did not reveal suspicion of adenomyosis. Therefore, the diagnosis of adenomyosis is not of significant suspicion in this patient and hysterectomy is not medically necessary. Moreover, the requested anterior and posterior repairs are indicated for the surgical management of cystoceles and rectoceles, respectively. However, there is a lack of documentation in the medical records provided for review that this patient has a cystocele or rectocele.  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. Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.Findings:  Three physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Final Result: Three reviewers determined that the diagnostic procedure 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: All three physician reviewers are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Decision DX melanoma multivariate gene expression assay for evaluation of the enrollees cutaneous melanomaFindings:  Three physician reviewers found that the Decision DX melanoma multivariate gene expression assay was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The patient presents with a recent history of lentigo maligna melanoma involving the upper back.  The patient was treated with local excision which is considered to be standard of care for his 0.39 mm Breslow depth melanoma. Decision DX melanoma testing was developed using genetic mutations identified in ocular melanoma. The usage and applicability of the Decision DX melanoma assay to cutaneous melanomas has not been established in the peer-reviewed literature. Moreover, the use of Decision DX melanoma testing is not the standard of care in this clinical setting. Final Result: 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: All three physician reviewers are board certified in dermatology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX colon cancer assay test for evaluation of the enrollees malignant neoplasm of colon. Findings:  Twp physician reviewers found that the patient was diagnosed with colon cancer in 2015. The patient had resection of their cancer in September 2015. The pathology was that of a moderately differentiated, grade 2, invasive adenocarcinoma. There was penetration through the bowel wall, and 15 nodes were negative. Therefore the patients pathologic stage was stage II. As part of the decision making about the need for adjuvant chemotherapy, her tissue was sent for Oncotype DX colon cancer assay. While the medical literature indicates that adjuvant chemotherapy benefits patients diagnosed with stage III (node positive) colon cancer, there is a lack of convincing data as to its benefits to patients with stage II (node negative) colon cancer, as in this patients case. The National Comprehensive Cancer Network states there is not as yet sufficient evidence to incorporate Oncotype in the treatment decisions about stage II colon cancer. Oncologists make this decision by looking at specific pathologic and clinical features in an individual case. Among the features that identify a higher risk of recurrence are a poorly differentiated carcinoma, stage T4, presentation with perforation or obstruction, lymphovascular invasion, or less than ten nodes having been examined. None of these features are present in this patient. There is a very limited consensus in the medical literature that one can use the Oncotype assay to predict benefit from adjuvant chemotherapy. For this reason, this type of test is not accepted as standard of care by the American Society of Clinical Oncology.  Final Result: Two 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 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 Daklinza and sofosbuvir for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi (sofosbuvir) and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population. The information provided is sufficient to meet the recommendations in the guidelines. Furthermore, delay in treatment may result in decreased survival. For these reasons, hepatitis C treatment is needed, and sofosbuvir with Daklinza for 12 weeks is s medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 iStent surgery (CPT 0191T) for treatment of the enrollees glaucoma.    Findings:  Two physician reviewers found that the records provided for review document that this patient has mixed glaucoma which is described as stable. The patients intraocular pressures are in the normal range and the cupping of the optic nerves is not severe. However, the records do not include the patients visual fields or long-term trends in the progression of glaucoma. In addition, the documentation lacks specificity regarding prior medications used to treat the patients medical condition. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology 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 reconstructive surgery to remove excessive skin for treatment of the enrollees medical condition.Findings:  The physician reviewer found that the requested procedure is cosmetic in nature and is not reconstructive in nature. Overall, there has been insufficient documentation to support that there is a functional deficit related to this patients excess soft tissue.  Typical symptoms, including chronic rashes, have not been described.  In addition, review of the photographs do not support that the patient has a significantly abnormal appearance.  A clear functional deficit that has failed standard dermatologic treatment and is associated with a significantly overhanging pannus has not been adequately defined. Based on the documented small size of the overhanging abdominal pannus and the lack of documentation of a functional deficit, the requested procedure is not medically indicated in this clinical setting. Final Result: The reviewer determined that the requested procedure is not reconstructive in nature and 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 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 budesonide for treatment of the enrollees chronic ulcerative colitis and Barretts esophagus. Findings:  The physician reviewer found that the use of oral budesonide for active ulcerative colitis is not supported due to a lack of effectiveness. Budesonide was not more beneficial than placebo. There is no evidence to recommend the clinical use of oral budesonide for the induction of remission in active ulcerative colitis. A budesonide multi-matrix (MMX) formulation is available as 9 mg extended release and has been demonstrated to be more effective than placebo for ulcerative colitis. However, there is a lack of data supporting the requested budesonide 3 mg three times daily as medically necessary for the treatment of this patients ulcerative colitis. 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 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 Xeljanz for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the current peer-reviewed guidelines do not support the use of Xeljanz without demonstration of failure of treatment with methotrexate and at least two anti-tumor necrosis factor (TNF) inhibitor biologic agents. The available medical records do not document failure of at least two anti-TNF agents in this patient. On the basis of this lack of documentation and per the peer-reviewed medical literature, the request for Xeljanz is not medically necessary for treatment of this patients rheumatoid arthritis. 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 rheumatology 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 for the continuous passive motion (CPM) machine for the treatment of the enrollees status post left knee arthroscopic surgery. Findings:  The physician reviewer found that the effects of continuous passive motion on knee range of motion are too small to justify its use.  Final Result: The reviewer determined that the equipment at issue was 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Qsymia 7.5-46 mg extended release (ER) capsules for treatment of the enrollees migraine and obesity.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Qsymia is not indicated for the treatment of migraine. Qsymia is U.S. Food and Drug Administration (FDA) approved for the treatment of obesity. Qsymia for the treatment of obesity is not medically necessary for this patient. There is a lack of documentation showing that the patient has tried and failed weight loss through an exercise program. Therefore, the request for Qsymia 7.5-46 mg ER capsules is not medically necessary.  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: Physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Azor for treatment of the enrollees hypertension. Findings: The physician reviewer found that the request for Azor has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient presents with hypertension who has previously been treated with Diovan and Cozaar at a low dose of 25 mg per day. There is no documented intolerance to the above medications. The dose of Cozaar prescribed was very small. In this clinical setting, treatment with Azor is not medically necessary, given that dose escalation has not been tried and other preferred angiotensin receptor blockers are available.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 cardiovascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees antiphospholipid syndrome.  Findings: Two reviewers found that Antiphospholipid syndrome is a serious disorder of abnormal arterial and venous thromboses. Antiphospholipid syndrome is an autoimmune disorder where antibodies are generated against self-antigens that drive the clotting cascade. Some patients have antiphospholipid syndrome and systemic lupus erythematosus whereas others have antiphospholipid syndrome alone. Anticoagulation is the mainstay of therapy, which includes enoxaparin, warfarin, and aspirin. Some studies have suggested that the addition of Plaquenil may be effective in preventing thromboses. All these therapies were tried in this case but the patient still developed clots. Rituxan is a monoclonal antibody directed at CD20, an antigen expressed on B cells. Thus, Rituxan can induce B cell cytopenia and reduction in antibody producing B cells. Rituxan is commonly used in autoimmune disorders based on this mechanism (Gurcan, et al; Rastetter, et al; Zaja, et al). Therefore, Rituxan has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication is 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 internal medicine with sub-specialty certification in medical oncology and hematology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi 400 mg tablets 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.  This applies regardless of fibrosis stage or viral load.  This patient should be considered treatment-naive as he has failed peg-interferon rather than peg-interferon with ribavirin in the past.  At this time, the guidelines do not recommend Sovaldi with ribavirin for this patient with hepatitis C, genotype 2 infection.  This is based on the significantly higher effectiveness of two other regimens, Epclusa, and Sovaldi with Daklinza.  For these reasons, the requested medication regimen is not medically necessary for the treatment of this patient.Final Result: The reviewer 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 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.