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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral balloon dilation of the maxillary sinuses and right concha bullosa resection surgery for treatment of the enrollees recurrent sinus infections. Findings:  The physician reviewer found that Chronic rhinosinusitis was not documented in this patient: there was no documentation of 12 weeks of consecutive disease. With regards to recurrent acute sinusitis, this diagnosis was not documented in this patient. There was no documentation of four or more recurrent episodes with complete clearing of symptoms between episodes over a one year period. There was no documentation of chronology of disease, symptoms or treatment. Accordingly, this patient did not meet the criteria for balloon sinuplasty. In sum, bilateral balloon dilation of the maxillary sinuses and right concha bullosa resection surgery were not likely to have been more efficacious than other available treatment options.  Final Result: Two of the three reviewers have determined that 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 reviewers are board certified in otolaryngology and are actively practicing. All three 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 Genotropin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of growth failure.Findings:  According to  the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SD) below the mean for age or more than 2 SD below the mid-parental height percentile; (2) growth velocity < 25th percentile for bone age; (3) bone age more than 2 SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. According to the submitted record, this patient meets most of the above criteria. Therefore, continuation of GH therapy for treatment of the patients idiopathic short stature has been demonstrated as medically necessary. Final Result: The reviewer has determined 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 pediatrics with a sub-specialty certification in pediatric endocrinology 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 reimbursement and prospective authorization and coverage for acupuncture services provided. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollee who has a history of headaches.Findings:  According to the medical research, acupuncture is considered effective for migraines and headaches. Acupuncture plus routine care in patients with headache were associated with marked clinical improvements compared with routine care alone. There is consistent evidence that acupuncture provides additional benefit for treatment of acute migraine attacks. Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment, and has fewer adverse effects. Acupuncture should be considered as a treatment option for patients willing to undergo this treatment. However, in this patients case, it is unclear how many sessions of acupuncture have already been rendered. There is support in the medical literature for the acupuncture sessions already performed. Accordingly, acupuncture services provided were medically necessary for the treatment of this patients medical condition. With regards to future visits, this should be requested based on documented progress and/or improvement as well as the total number of rendered acupuncture visits. Such documentation is currently lacking in this case. For these reasons, acupuncture services provided were medically necessary for the treatment of this patients medical condition. However, future services have not been demonstrated as medically necessary, at this time.Final Result: The reviewer has determined a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications:  The reviewer is board certified in oriental medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for autonomic thermoregulatory testing, autonomic testing, and the quantitative sensory testing. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees choristoma of the left sciatic nerve.Findings:  The patient had developed weakness in the left lower extremity associated with sensory problems. The patient was subsequently diagnosed with hamartoma of the lumbosacral and sciatic nerve. There was no evidence provided in the submitted documentation that was suggestive of clinical signs of autonomic dysfunction. In addition, there was no clear justification provided for the quantitative sensory testing in this case. Moreover, there was no information about how these tests were likely to change the patients management. The patient was diagnosed with a hamartoma  which explained the patients symptoms. For these reasons noted above, the autonomic thermoregulatory testing, autonomic testing, and the quantitative sensory testing were not likely to be more beneficial than the available standard therapy for the evaluation of this patient.Final Result: All three reviewers have 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 reviewers are board certified in neurology and are actively practicing. All three 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 prothrombin G20210A mutation test. The Health Plan has denied this request indicating that the services at issue were considered investigational for evaluation of the enrollees medical condition.Findings:  There is support in the medical literature for the efficacy of the services at issue in this clinical setting. The prothrombin G20210A mutation is the second most common inherited thrombophilia after the factor V Leiden mutation.  The mechanism by which the prothrombin G20210A mutation increases the risk of thrombosis is not completely understood but is thought primarily to involve an increased concentration of prothrombin in the circulation. The major clinical manifestation of the prothrombin G20210A mutation is venous thromboembolism (VTE). A slight risk of arterial thrombosis may exist in certain settings. A meta-analysis by Kim and Becker evaluated the association of inherited thrombophilias with arterial thromboembolic events (myocardial infarction, ischemic stroke, or peripheral vascular disease) and reported an association between the prothrombin G20210A mutation and arterial events. In summary, prothrombin G20210A mutation test was likely to have been more effective than the standard options available for the evaluation of this patients medical condition. Final Result: Two of the three reviewers have determined that the services at issue were likely to be more beneficial for evaluation of your medical condition than any available standard therapy.Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three 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 Eliquis. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees deep vein thrombosis.Findings:  The documentation supports the medical necessity of the treatment in question. The patient has documentation of left lower extremity DVT. The medication Eliquis is an approved medication for the treatment of DVT. The records indicate the patient has developed an intolerance to the medication Coumadin with reported bruising and nose bleeds. Therefore, the requested medication Eliquis has been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has 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 vascular 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 Lyrica. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees arthritis.Findings:  The submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. In the documentation submitted for review, there is a lack of objective treatment goals for pain and function. Behavior therapy has been discussed but has not been completed despite much research to support its use. In addition, the records do not indicate that all non-opioid medication classes have been optimized or tried. Specifically, there is no mention of adding a tricyclic antidepressant, and/or gabapentin noted. In addition, there are other forms of treatment options available to this patient. Finally, since there is anxiety noted, the addition of Lyrica is not recommended. For all of these reasons, the requested authorization and coverage for Lyrica has not been demonstrated as medically necessary for treatment of this patients medical condition.Final Result: The reviewer has 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 anesthesiology with sub-specialty certification in pain 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 patient has requested authorization and coverage for Contrave 8 mg-90 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients obesity. The submitted documentation fails to demonstrate the medical necessity of the requested medication. Contrave is U.S. Food and Drug Administration approved for the treatment of obesity. It is used in adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults with an initial body mass index greater than 30 kg/m2 or greater than 27 kg/m2 in the presence of at least one weight-related comorbid condition, including hypertension, type II diabetes mellitus, and/or dyslipidemia. Initial management of individuals who would benefit from weight loss is a comprehensive lifestyle intervention consisting of a combination of diet, exercise, and behavioral modification. Per the medical evidence, patients who would benefit from weight loss should receive counseling on diet, exercise, and goals for weight loss. When a patient with an initial body mass index greater than 30 kg/m2 or a body mass index of 27-29.9 kg/m2 with comorbidities, such as hypertension or diabetes mellitus, has failed to achieve weight loss goals through diet and exercise alone, a pharmacologic therapy is suggested. In this case, the documentation does not support that the patient has failed treatment with counseling, calorie restriction, and increased physical activity to achieve weight loss goals. The record indicated that the patients body mass index was 31.24 kg/m2. However, the records did not indicate that there was a recent office visit to support that the patient has comorbid health conditions or a recent failure of diet with exercise. Therefore, Contrave 8 mg-90 mg 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transoral incisionless fundoplication (TIF) with EsophyX device. The efficacy of transoral incisionless fundoplication has been studied in randomized controlled trials. However, the conclusions are contradictory. A large randomized trial included 60 patients and found no improvement in esophageal acid exposure compared with baseline at 12 months. The study concluded that no long-term objective reflux control was achieved. Guidelines do not recommend endoscopic procedures for patients with complicated gastroesophageal reflux disease, which the guidelines define as dysphagia or Barretts esophagus, both of which the patient has, and report that the long-term follow-up data for TIF is limited.  These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. For these reasons, transoral incisionless fundoplication is not 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 services are 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: 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 placental membrane graft and Grafix Prime. Findings:  Three physician reviewers determined there is a lack of support for the services at issue in this clinical setting. Research found a randomized controlled trial utilizing Grafix for diabetic foot ulcer wounds. There were 50 patients in the Grafix group and 47 patients in the control group.  Although the wound healing rates were higher in the Grafix than the control group, the sample size was small and the population had a different clinical problem (diabetic foot ulcers) than this patient with pyoderma gangrenosum. There is a lack of literature to specifically support the use of Grafix in lower extremity wounds secondary to pyoderma gangrenosum. A review on pathogenesis and treatment of pyoderma gangrenosum recommends a combination of wound care, topical therapies, and systemic therapy for moderate to severe disease. In sum, placental membrane graft and Grafix Prime were not likely to have been of greater benefit than other treatment options. Final Result: The 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: Physician reviewers 1 and 2 are board certified in surgery and are actively practicing. Physician reviewer 3 is board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100 mg-40 mg tablets for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. The submitted documentation supports the medical necessity of the requested medication regimen. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all enrollee with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that all enrollees should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1a enrollee should be treated with Mavyret for eight weeks. ASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg tablets for eight weeks are medically necessary for this enrollee.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the enrollees 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 genetic testing. Findings:  Two of the three physician reviewers found fetal aneuploidy screening is supported for all pregnant patients by the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine. Cell-free DNA testing has been validated as having a high detection rate for fetal chromosomal abnormalities, including sex chromosomes. There are several commercially available tests, including MaterniT21. Currently, the non-invasive screening test of choice for aneuploidy is cell-free DNA testing, regardless of the patients age. However, aneuploidies are more common in patients older than 35 years. Part of the commercial testing includes an analysis of fetal sex chromosomes. Fetal sex chromosomal abnormalities are common. Sex chromosome abnormalities such as Turners syndrome include significant associated medical morbidities. There is sufficient support for the services at issue in this clinical setting. This technique has been highly validated and shown to have a high detection rate. This testing allows patients to make important clinical decisions regarding the pregnancy. Therefore, genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: A female enrollee has requested authorization and coverage for metformin ER 1000 mg. A study found some formulations of extended release metformin preparations have been demonstrated to have more tolerability compared to immediate release preparation. The patient has tried and failed the immediate release metformin in the past. However, there is no documentation to support that the patient has tried and failed metformin extended release (Glucophage XR) preparation which is a formulary alternative. Thus, the requested metformin ER 1000 mg is not supported as medically necessary for treatment of this patients type 2 diabetes. 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 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.