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 Stelara. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. A letter from the provider indicated an adverse effect of frequent injections from Enbrel or Humira. However, the submitted records do not document a treatment trial with Enbrel or Humira nor do the records document which adverse effects were experienced with these medications. Consequently, there is no clear indication that Enbrel or Humira would not be an effective treatment option for this patient. In this patients case, other effective therapies may be available. As such, Stelara is not medically necessary for treatment of this patient.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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were not necessary for treatment of a psychiatric emergency medical condition. According to the documentation submitted for review, the patient was admitted to a wilderness program due to behavioral and self-esteem issues. There is no documentation to support that the treatment provided was emergent due to acute symptoms. The patient did not have a psychiatric emergency medical condition during the dates in dispute. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Thiola 100 mg for treatment of the enrollees recurrent cystine stones. Findings:  The physician reviewer found that the request for Thiola 100 mg is medically necessary for treatment of the patients medical condition. The patient has a very difficult condition with repetitive formation of cystine stones. Thiola is medically necessary to prevent further stone formation with or without the combination use with penicillamine and hydration, alkalization of the urine and diet modifications. Given the patients young age and the extent of stone formation, treatment with Thiola 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 urology 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 left ventricular assist device for treatment of the ventricular tachycardia, congestive heart failure, and hypertension. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. According to the records, the patient has severe cardiomyopathy and documented ongoing noncompliance with medication as well as ongoing drug abuse with methamphetamine. In this circumstance, documented medication noncompliance and ongoing drug abuse are established contraindications to cardiac transplantation and other device related advanced heart failure therapy. Compliance with prescribed medications and absence of drug abuse are both essential to successful management of patients with a left ventricular assist device placement.  Current guidelines endorsed by several national organizations are also consistent with this approach. Final Result: The reviewer determined that the requested device 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 authorization and coverage for spine nerve treatment (radiofrequency neurolysis).Findings:  The physician reviewer found that Percutaneous neurolysis for chronic neck and back pain is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The majority of peer reviewed literature supports the efficacy of radiofrequency neurolysis in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. In reviewing the medical records, the MRI is significant for multilevel spondylosis. Per the providers notes, the patient had good but short term relief with cervical medial branch blocks. This patient meets the guidelines for radiofrequency neurolysis with two cervical medial branch blocks, which provided greater than 80% and greater than 90% reduction in pain. Radiofrequency facet neurolysis is, therefore, appropriate in treating the patient. In sum, spine nerve treatment (radiofrequency neurolysis) is likely to be more effective than the other available methods of treating this patients medical condition.Final Result: Two of the  three 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: Physician reviewers 1, 2 & 3 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: The patient has requested authorization and coverage for Vemlidy. Findings:  The physician reviewer found that Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease . For this reason, the requested Vemlidy is supported as medically necessary for the treatment of this patients chronic hepatitis B. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene test (molecular profiling). Findings:  The physician reviewer found that a pheochromocytoma is a rare neuroendocrine tumor of the medulla of the adrenal glands or extra-adrenal chromaffin tissue that failed to involute after birth, which secretes high amounts of catecholamine. This condition potentially leads to symptoms which are consistent with sympathetic nervous system hyperactivity. Although pheochromocytomas are usually sporadic, about 30% of these tumors have been identified of inherited origin. Furthermore, a pheochromocytoma may be a manifestation of certain syndromes, such as MEN2.  The medical evidence reports that it is important to screen for these syndromes in order to identify comorbid potential neoplasms and disorders, such as medullary thyroid carcinoma and hyperparathyroidism. With proper identification of these conditions, it is possible to treat preventatively or early in the course of the illness, thereby limiting potential future morbidity.  For these reasons, the gene test (molecular profiling) provided was likely to have been of greater benefit than the available standard options for the evaluation of this patients medical condition. Final Result: All three of 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 & 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 DecisionDx-Melanoma gene test. Findings:  The physician reviewer found that Melanoma staging is characterized by the American Joint Committee on Cancer (AJCC) system that defines cutaneous melanoma stages 0-IV. While the majority of clinical stage I patients will be disease-free at five years, some stage I patients will develop advanced disease. As patients diagnosed with stage I or II melanoma are generally viewed as having a low risk of metastasis, treatment planning is limited to surgical excision of the primary tumor followed by routine skin examinations and clinical examination. In contrast, patients diagnosed with stage III melanoma receive complete lymph node dissection, active surveillance measures and often, referral to medical oncology for adjuvant medical therapy and clinical trial participation. DecisionDx-Melanoma assay assesses the expression of 31 genes that have been associated with metastasis and classifies tumors as class 1 consistent with a low risk of metastasis or class 2 suggestive of a high risk of metastasis. Sidiropoulos and colleagues indicated that there was a statistically significant association of a class 1 signature by DecisionDx-Melanoma assay for primary dermal melanoma (PDM), whereas cutaneous metastatic melanoma (CMM) were more frequently class 2. The authors concluded that the melanoma prognostic assay may be a useful tool for distinguishing PDM from CMM. According to the results of analysis of this patients melanoma performed with DecisionDx-Melanoma assay, the tumor was classified as class 1 with a low risk of near term (within five years) metastatic disease. Therefore, DecisionDx-Melanoma signature may be an independent predictor of metastasis risk. However, there is a lack of peer reviewed published studies confirming this hypothesis. In sum, DecisionDx-Melanoma gene test provided was not likely to have been more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three of the 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: Physician reviewers 1, 2 & 3 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 the brain imaging tomographic scan for evaluation of the enrollees chronic fatigue. Findings:  Two physician reviewers found that the SPECT scan is a functional test of brain metabolism and has been used for a number of clinical neurologic and psychiatric disorders. In this case, the patient has chronic fatigue syndrome. The medical records provided for review fail to include a rationale for the SPECT scan provided in this case. The patient presented with subjective symptoms, however there were no significant objective findings documented except for adrenal insufficiency which was poorly responsive to cortisone supplementation. There is a lack of medical literature supporting the SPECT scan in the diagnosis of neurologic or psychiatric disorders, except for some specific conditions such as dementia and brain injury. All told, the brain imaging tomographic scan performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the service 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: Reviewers 1, 2 and 3 are board certified in neurology 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 DecisionDx-Melanoma gene test for evaluation of the enrollees cutaneous melanoma. Findings:  Three physician reviewers found that the standard protocol based on National Comprehensive Cancer Network (NCCN) guidelines for an intermediate thickness tumor, like this patients, does not include a workup with molecular genetic testing. Currently, although the testing has shown some impressive results in predicting risk of metastasis, there is no set change in treatment protocol based on the findings. Currently, the protocol would be a wide local excision and a sentinel node biopsy and the decision to pursue medical treatment would be based on the results of these tests. There is a lack of clinical studies at this time to show that the results of the molecular testing will make a difference in the treatment or morbidity of the patient. Final Result: The 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: Reviewers 1, 2 and 3 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for modafinil 100 mg for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that as noted in the medical literature, stimulant medications are considered the gold standard pharmacologic intervention for attention deficit hyperactivity disorder (ADHD). Per the American Psychiatric Association (APA), stimulants such as methylphenidate and amphetamine salts are the two major categories of pharmacological treatment for ADHD and are considered the first-line medication treatments for the disorder. Modafinil is not a stimulant, rather it is a wake promoting agent that selectively increases neuronal activity in the hypothalamus, particularly in the wakefulness center of the tuberomammillary nucleus. The medication is approved by the U.S. Food and Drug Administration (FDA) for excessive sleepiness associated with narcolepsy, obstructive sleep apnea and shift-work sleep disorder. Due to several promising studies, the FDA considered modafinil for ADHD in 2006, but due to concerns of Stevens-Johnson syndrome and the absence of rigorous scientific trials demonstrating the long-term safety and efficacy of the medication, modafinil is not recommended for treatment of ADHD. In this patients case, there is no evidence in the records that formulary equivalents would be inappropriate, unsafe or inadequate. Indeed, the patient did well with Dexedrine for at least 10 years, and it appears that the medication, as well as newer FDA approved options such as lisdexamfetamine and dexmethylphenidate, are on the formulary and available to this patient. Additionally, there is no interpretative summary or clinical rationale in the medical documentation that supports atypical dosing of modafinil for ADHD. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of anemia.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue. A review of the medical literature finds that while there are reported associations of MTHFR polymorphisms with several conditions, there are very limited clinical indications for testing for polymorphisms in the MTHFR gene, as these associations have not been shown to have clinical significance.  In addition, there is scant evidence for the use of this genetic test in the evaluation of folate and/or vitamin B12 deficiency. All told, gene testing was not 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 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: Reviewers 1, 2 and 3 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Game Ready cooling device with pneumatic pressure. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the superior efficacy of the device at issue in this clinical setting. Generally, cold compression is recommended as an option for home rental for up to seven days following major knee surgery, but not for routine arthroscopic procedures or nonsurgical treatment. The available literature has not demonstrated long-term functional improvement outside the acute postoperative period to support the use of this unit over traditional cold therapy with ice packs and compression. Therefore, these more complex devices are recommended to be reserved only for more complex and painful knee procedures such as periarticular fractures and revision arthroplasty. In this case, the patient underwent an arthroscopic anterior cruciate ligament reconstruction and medial meniscus repair.  Therefore, the Game Ready cooling device with pneumatic pressure was not likely to have been more effective than other treatment options.  Final Result: Two of the three reviewers determined that the device at issue was 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 & 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