Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male enrollee has requested authorization and coverage for Linzess. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated in adults for treatment of constipation due to inflammatory bowel syndrome and chronic idiopathic constipation. The available records support that this patient has documented chronic idiopathic constipation. He meets the medical definition of constipation given his history of infrequent bowel movements, difficulty during defecation, or the sensation of incomplete bowel evacuation. The patient has already benefitted from and tolerated treatment with Linzess. He has documented failure to benefit from Amitiza, docusate, Senna, Ex-Lax, lactulose, and fiber supplementation. Accordingly, Linzess is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewer determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Nature of Statutory Criteria/Case Summary: Findings:  The physician reviewer found that a review of the submitted documentation does not support the medical necessity of the requested services. The records indicate the patient has undergone appropriate evaluation for gender dysphoria according to 2017 Endocrine Society clinical practice guidelines. Based upon the most recent documentation provided, the patient has taken hormonal treatment for reassignment to the male gender for approximately 20 months. The 2017 Endocrine Society guidelines state, Because some transgender male adolescents present after significant breast development has occurred, they may also consider mastectomy 2 years after they begin androgen therapy and before age 18 years.  In this patients case, the records demonstrate that he has not received hormone therapy for a full 24 months, and was not compliant with hormonal therapy as recently as December 2017. Thus, the patients hormonal treatment is not aligned with the most recent Endocrine Society mastectomy guidelines for adolescents. Further, the patients lack of compliance with hormonal therapy suggests that his maturity level and level of engagement are not consistent with the pursuit of gender reassignment surgery at this time. As such, the requested bilateral mastectomy to be performed on an outpatient basis is not medically necessary.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 psychiatry with sub-specialty certification in child and adolescent psychiatry and expertise in treating gender dysphoria 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: Anenrollee has requested reimbursement for intensive outpatient program (IOP) services. The progress notes during the disputed dates indicate that the patient has been cooperative in treatment. Much of the patients initial anxiety was based around her neck pain, which substantially improved with treatment. She had a significant period of sobriety and continued to maintain her sobriety during treatment. She was noted to be adherent to her Suboxone treatment. The records do not indicate any severe mood symptoms or psychosis. The patient did not report any suicidal or homicidal ideation and was not exhibiting any behavioral issues. She was described as motivated for treatment. The progress notes did not reflect any severe symptoms that required continued treatment multiple times per week in an IOP. In addition, applying the Level of Care Utilization System (LOCUS), the IOP services were not and are not medically necessary for treatment of this patients behavioral health issues. The patient has no risk of harm (score 1) due to a lack of suicidal ideation, and her functional status has been mild to moderate (score 3). The patient is medically stable (score 2) with improvement of her neck pain and no severe psychiatric issues. The patient has a mild to moderately stressful recovery environment (score 3) due to her housing situation. The patient also has a limited level of support in her recovery environment (score 3) due to a history of substance use in and her family and some potential issues with sober living. The patient has demonstrated significant positive response to recent treatment (score 2) and has been cooperative in treatment (score 2). This gives the patients presentation a composite score of 16, which correlates with low intensity community based services, such as outpatient services. Given these findings, the IOP services were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xyrem 500 mg/mL solution, 4.5 grams, two times per day. Xyrem is a central nervous system depressant that has been approved by the U.S. Food and Drug Administration (FDA) the treatment of narcolepsy. Narcolepsy is a common cause of daytime sleepiness. It is a syndrome of daytime sleepiness with cataplexy, hypnagogic hallucinations and sleep paralysis. In order for a diagnosis of narcolepsy to be made, both a polysomnogram and multiple sleep latency test (MSLT) should be performed. The diagnosis of narcolepsy is confirmed with a polysomnogram that rules out other sleep disorders and a MSLT that demonstrates an average sleep latency less than eight minutes and/or at least two sleep onset rapid eye movement periods. In this case, the documentation submitted for review does not show that the patient has had a detailed sleep assessment or confirmatory testing. It appears that the requested medication has been used for a diagnosis of chronic fatigue syndrome, and this is not an FDA approved indication. Therefore, for Xyrem 500 mg/mL solution, 4.5 grams, two times per day is not medically necessary for the 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 59-year-old female enrollee has requested authorization and coverage for Estradiol 0.01% cream/appl. This patient has vaginal symptoms secondary to menopause and tissue atrophy due to estrogen deficiency. The standard treatment for this condition is estrogen therapy. The route of delivery is variable and depends on the patient. In this case, there is no documentation that the patient could not tolerate or did not respond to the preferred formulary treatment options, including generic Vagifem. Thus, the requested Estradiol 0.01% cream/appl is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for air ambulance services. A patient might require air ambulance services in order to be transferred from one institution to another in order to receive specialized services. In such a case, the patient must be transferred to the closest facility capable of providing the specialty services. Per the submitted documentation, there were alternative facilities capable of providing inpatient rehabilitation for this patient. This patient was stable for discharge at the time of his transport. He was not transferred for a higher level of care that could not be provided at the sending institution. The patient was described as medically stable for discharge to a rehabilitation facility. The patient did not receive intravenous medications during transport. His oxygen saturation was normal on room air. No acute intervention was required. The services at issue were not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services.Final Result: The reviewer determined that the patient did not receive emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in emergency 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 authorization and coverage for Transderm-Scop 1.5 mg patches.  Findings:  The physician reviewer found that There is a lack of support for the requested medication in this clinical setting. Transderm-Scop 1.5 mg (scopolamine) is an anticholinergic medication that is U.S. Food and Drug Administration (FDA) approved for the prevention of nausea/vomiting associated with motion sickness and recovery from anesthesia and surgery. Motion sickness is a syndrome that occurs in response to real or perceived motion. Scopolamine patch and antihistamines are used for the treatment of motion sickness. Scopolamine is not considered more effective than antihistamine medications. In this case, the documentation does not support that the patient has been treated with formulary antihistamines. There is no documentation that these medications would not be effective for the patient, and she has not had any documented adverse effects to these medications. Therefore, Transderm-Scop 1.5 mg patches are not medically necessary for the 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Harvoni 90-400 mg, one tablet daily for eight weeks. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on randomized clinical trial data showing a high cure rate with this regimen. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Additionally, the guidelines do not recommend NS5A resistance testing routinely prior to use of Harvoni.  For these reasons, Harvoni 90-400 mg, one tablet daily for eight weeks 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser ADA diagnostic testing. Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, there are few well-controlled clinical trials to confirm that use of the Anser ADA diagnostic testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. Thus, Anser ADA diagnostic 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A male 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of this patients hepatitis C infection.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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the DecisionDx-Melanoma Gene Assay testing. Although potentially beneficial, there is currently a paucity of scientific data demonstrating improved patient outcomes with use of gene expression profiling to direct treatment decisions. There have been reported inconsistencies in results across studies aimed at defining the most predictive sets for melanoma. In addition, per the National Comprehensive Cancer Network (NCCN) guidelines, adjuvant immunotherapy is indicated for stage III disease and is not governed by the results of molecular profiling. For these reasons, the DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the DecisionDx-Melanoma Gene Assay testing 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 DecisionDx-Melanoma Gene Assay testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for molecular markers test. Findings:  Two of the three physician reviewers found molecular diagnostic studies in non-small cell lung cancer (NSCLC) are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with NSCLC.  Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Thus, molecular markers test was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined 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.