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 removal of fibroma on tongue for the treatment of the enrollees fibroma. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested services. Clinically, benign lesions of the tongue are usually asymptomatic and may appear in the majority of circumstances as a result of minor trauma. The usual management of small lesions less than 5 mm is careful observation, unless there is functional impairment. Per the medical records, this patients lesion measures only approximately 3 mm.  Although the patient complained of minor bleeding, this does not qualify as an impairment of function. The records do not document that chewing, eating, swallowing or taste were impaired from the presence of the tongue lesion. The patient reported that the lesion affected her speech and work as a music teacher. However, the degree of impairment was not specified.  The submitted records do not demonstrate that the patient underwent a speech evaluation to determine the degree of functional impairment. The clinical notes from the provider did not indicate that the patient had any form of dysarthria or speech impairment as a result of the lesion. The current medical evidence does not support removal of the small lesion in this clinical setting. All told, removal of fibroma on tongue 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 otolaryngology 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 polysomnography for evaluation of the enrollees obstructive sleep apnea.Findings:  The physician reviewer found that The physician reviewer found that this patient has documented obstructive sleep apnea that has been well-treated since 2011 with to bilevel positive airway pressure (BiPAP).  Recent records noted that the patients hypertension and diabetes were well-treated. On the date the polysomnogram was ordered, there was no documentation of daytime hypersomnia, driving accidents, poorly controlled hypertension, poorly controlled diabetes, or any difficulty with using BiPAP. The office note did not indicate why another polysomnogram was ordered. Any slight adjustments in BiPAP can be done with the use of the smart card compliance data that can document the apnea hypopnea index during sleep. Based on the documentation provided for review, the requested polysomnography is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. Based on the diagnoses listed by the treatment facility, the patient more than likely needed comprehensive specialty care for her substance use. However, there was no report of the illness burden, health impacts, psychosocial sequelae or patterns of drug use that prompted the admission. Further, there was no mention of psychiatric comorbidity.  Finally, there was no evidence that the patient had failed a less restrictive setting during the episode of illness or that community-based treatment would have been unsafe or inadequate at the time.  A validated rating scale for alcohol withdrawal suggested that medication was not necessary. The patients vital signs were within normal limits, and she denied any pain. As such, the patient was not enduring complicated withdrawal syndrome. The documentation provided did not include a treatment plan, psychosocial assessment, psychiatric evaluation, interpretive summary or a clinical rationale supporting the need for residential placement as opposed to treatment at a lower level of care. Considering the clinical presentation and patient history, residential treatment center services were not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The patient has requested authorization and coverage for bevacizumab (Avastin) treatment of the enrollees lung cancer. Findings:  All Three physician reviewers found that The physician reviewer found there are currently no standard regimens for use in this patients clinical setting. However, Avastin has been shown to prolong survival in patients when given in combination with paclitaxel/carboplatin in first-line therapy (Sandler, et al). It has also been combined effectively with docetaxel or pemetrexed. As demonstrated by Herbst and colleagues, Avastin was combined with single agents and showed an advantage in terms of one year survival rates. Some recent abstracts presented at the American Society of Clinical Oncology also support other combinations with Avastin that show significant response. Thus, the providers recommended combination therapy including Avastin is appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: All three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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: he enrollee has requested authorization and coverage for Xeljanz XR (extended release) for treatment of the enrollees rheumatoid arthritis.Findings:  The physician reviewer found that the 2015 American College of Rheumatology (ACR) Guideline for treatment of rheumatoid arthritis recommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi. In this patients case, the documentation provided indicates failure of multiple disease-modifying antirheumatic drugs. Previous treatments have included methotrexate 17.5 mg, which was stopped in February 2017 because the patient was not able to tolerate the therapy. Plaquenil and Humira were partially effective, but the patient has a fear of needles. The patient has an allergy to Remicade. Actemra and Orencia were also ineffective. The patient has been on Xeljanz since February 2017 with one tender/swollen joint, normal DAS28erythrocyte sedimentation rate/Creactive protein and low disease activity. The record is clear that this patient has tried and failed two different TNFi (Humira and Remicade). The patient has also failed two non-TNF biologic agent as recommended by 2015 ACR guidelines (Orencia, Actemra).  During her April 2017 evaluation, there was improvement in her symptoms but her examination remains unchanged. As such, Xeljanz XR is medically necessary. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks with RibaPak for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the 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. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed PEG-interferon and ribavirin with a protease inhibitor should be treated with regimens including Zepatier and ribavirin for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 93% cure rate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier with RibaPak for 12 weeks is supported as 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the hormone implants (subcutaneous testosterone implants) for treatment of the enrollees hypogonadism. Findings:  The physician reviewer found that the Endocrine Society guidelines recommend testosterone therapy for symptomatic men with classical androgen deficiency syndromes aimed at inducing and maintaining secondary sex characteristics and at improving their sexual function, sense of well-being, and bone mineral density.Testosterone pellets were approved by the U.S. Food and Drug Administration (FDA) and have been proven to be effective at doses up to 10-12 pellets every three to four months in well selected patients.  This patient has proven low testosterone levels. In addition, the patient has not responded adequately to transdermal therapy. His levels remained subnormal and he continued symptomatic. All told, the testosterone pellets were properly administered to this patient with low testosterone levels that failed to transdermal preparations. Given these findings, the hormone implants (subcutaneous testosterone implants) were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two of the reviewers determined that the service at issue was 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 reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: The patient has requested authorization and coverage for dopamine transporter single photon emission computerized tomography (DAT SPECT) scan for evaluation of the enrollee who has a history of tremors.Findings:  The physician reviewer found that the patient presented to the provider experiencing balance disorder and uncontrolled tremors. The patient is enrolled in physical therapy once a week. The patient reported that tremors have decreased in intensity since stopping Zyprexa, but the patients anxiety aggravates tremors. The provider recommended diagnostic imaging to determine the etiology of the tremors. The patient has requested authorization and coverage for dopamine transporter single photon emission computerized tomography (DAT SPECT) scan. The Health Plan denied this request and reported that the requested services are investigational for the evaluation of this patients medical condition. DAT SPECT is an acceptable diagnostic technique for the assessment of tremor. In patients where the cause of tremor is not known or is likely to be caused by other diagnoses such as essential tremor, the use of a DAT SPECT scan can be helpful in determining the correct diagnosis. This scan has been widely used by clinicians when there is a question of the etiology of tremor. The early diagnosis of the cause of a tremor allows for better control of symptoms and allows the patient to access available resources quicker. Based on the information provided in the medical records, this patient is likely to benefit significantly from having the DAT SPECT scan over the available standard options for the evaluation of this patients medical condition. Final Result: The reviewers determined that the requested services are 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the gene expression classifier (GEC) testing for evaluation of the enrollees thyroid nodule. Findings:  The physician reviewer found that the Bethesda System recommends a diagnostic hemithyroidectomy for this type of nodule. The recent American Thyroid Association guidelines state that for nodules with atypical of undetermined significance cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If the genetic test is suspicious, the risk of malignancy increases to 40% and the risk of malignancy decreases to less than 6% with benign findings. In this case, the result of the Afirma GEC was suspicious for malignancy. This increases the patients risk of malignancy to 40%. This information was important to determine the decision whether to perform thyroidectomy, and if so, the extent of surgery. For these reasons, the Afirma GEC test provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 removal of myelolipoma from the right adrenal gland for the treatment of the enrollees myelolipoma. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that the physician reviewer determined that angiomyolipoma of the adrenal gland is a benign tumor that may cause symptoms due to the mass effect on adjacent organs or the retroperitoneum. It does not appear to either have biochemical/functional consequences, nor does it appear to have malignant potential. Therefore, therapy can be observation when the diagnosis is clear. If the diagnosis is unclear, then resection may be indicated to eliminate the possibility of a soft tissue lipomatous tumor. In selected cases, surgical resection may be indicated for relief of symptoms. In this patient's case, the diagnosis was clearly made on a core biopsy. Although the patient is complaining of abdominal pain, it is unclear if it is directly related to this tumor, as the patient also has a recurrent hernia. In addition, the pain is only of two months duration, and the tumor has been present for at least four years. Based on the records, the tumor does not appear to be rapidly enlarging in which imminent symptoms may prompt surgical resection. All told, the requested removal of myelolipoma from the right adrenal gland is not medically necessary for the treatment of this patient. Fulfills requirements of (1374.33)(h)(1)(H) and (K).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. Fulfills requirement of 1374.33(h)(1)(I)Credentials/Qualifications: The reviewer is board certified in surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. Fulfills requirement of (1374.33)(h)(1)(G)