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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Fentora for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Fentora has not been established. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, long-term opiates are more likely to cause adverse outcomes. Other researchers reported that prolonged use of high dose, opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  Given the above, Fentora as requested is not medically necessary for treatment of the 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 anesthesiology with sub-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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that 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 or viral load. Per the guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested allergen specific IgG testing for the evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The use of food-specific IgG levels does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  Per the medical evidence, food-specific IgG should not be used as a tool to diagnose food allergy, and the positive food should not be eliminated from the diet based upon results of these tests.  The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum.  Immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens.  Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  In conclusion, allergen specific IgG testing was not likely to be more beneficial for evaluation of the patients condition than other modalities.  Final Result: Three 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:  One reviewer is board certified in internal medicine and is actively practicing.  Two reviewers are board certified in internal medicine and allergy and immunology 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:  The parent of an enrollee has requested Nutropin AQ Nuspin for treatment of the enrollees growth hormone deficiency. Findings: The physician reviewer found that the review of the submitted documentation demonstrates the patient has extreme short stature, poor growth velocity, low growth factors, and a morphological abnormality of the pituitary gland that is known to be associated with GH deficiency. The patient has had an excellent response to GH therapy. GH therapy is medically necessary for treatment of GH deficiency until epiphyseal closure. In the setting of extreme short stature with morphological abnormality of the pituitary gland and unequivocally low IGF-1 level, provocative GH testing is not necessary to confirm the diagnosis. As such, the requested Nutropin AQ Nuspin 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 pediatrics with 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene testing (MTHFR) for the evaluation of his medical condition. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Studies have shown that clinically useful predictors are scarce for antidepressant therapy, and the results are inconsistent. They have shown that there is only marginal clinical association between enzyme system variants and selective serotonin reuptake inhibitor (SSRI) metabolism, efficacy, and tolerability in the treatment of depression. There is a lack of large randomized trials that have been conducted which would support the use of genetic testing in this case. The existing studies have indicated that there was no significant correlation between either genotypes or antidepressant serum concentration and response to antidepressant treatment. The current evidence does not support the use of genotyping when choosing an antidepressant.  Even less is understood about its utility in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the clinician towards choosing a medication regimen.  Therefore, the services at issue were not likely to have been more efficacious than other methods of evaluating this patient.  Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the American College of Radiology (ACR) statement has urged that tomosynthesis be removed from the investigational category due to the advantages the new technique brings to radiologists reading mammograms. These advantages relate to the ability to separate dense glandular elements from underlying architectural distortion thus reducing callbacks and increasing detection of small cancers. Tthe presence of a mass mandates complete evaluation by both mammography and ultrasound prior to assessing a probable diagnosis and recommendation for intervention if appropriate. In addition, in cases where the mammogram and ultrasound are suspicious it is imperative the entire breast be evaluated for not only the lesion in question but also for possible synchronous tumors. Tomosynthesis enables to the best advantage such evaluation. For this reason, the inclusion of tomosynthesis was likely to be of more benefit than two-dimensional (2D) imaging only. Final Result: Two 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:   All three reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. At the time of admission to residential treatment center services the patient did not have severe symptoms. He had the potential for relapse, but this potential in this population in and of itself is not a reason for 24-hour monitoring in the absence of other factors such as psychiatric comorbidity rendering him unstable in his recovery. He did not require 24-hour medical and nursing supervision, and could have safely and effectively been treated at a lower level of care, such as outpatient services with community resources. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. 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 physician 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:   The parent of an enrollee has requested growth hormone, Nutropin AQ, for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patients height is not more than 2 standard deviations below the mean for age and gender, and he has a normal growth velocity, normal pre-treatment IGF-1 level, and no known morphological abnormality of his pituitary gland. His bone age is delayed, but not due to GH deficiency. Based on the patients pre-treatment bone, the estimated final adult height is a normal adult height prediction and appropriate for the patients genetic potential. The patients peak GH response on provocative GH testing is borderline low, but such testing has poor sensitivity and specificity for a diagnosis of GH deficiency in the setting of normal growth velocity. Based on the medical literature cited above and the documentation submitted for review, the request for Nutropin AQ is not medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 physician reviewer is board certified 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 Xiaflex for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Peyronies disease is caused by scar tissue which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this can cause penile curvature with erection.  The curvature can make intercourse difficult and/or painful for the patient and his partner.  Potential treatment options for Peyronies disease include surgery, minimally invasive treatment options, and medications. The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  Per the medical evidence, the options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for the use of Xiaflex in this clinical setting.  All told, Xiaflex is medically indicated for the treatment of this patient.  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 Acthar Gel for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has been recently switched to a new medication regimen.  The medical records document significant improvement in pain and stiffness on the current regimen.  There is literature against the use of long-term corticosteroids in rheumatoid arthritis.  When corticosteroids are used for a period of one month or less, they are more effective than either placebo or a nonsteroidal anti-inflammatory drug.  Although Acthar is approved for flares in rheumatoid arthritis, there is a lack of evidence in the literature supporting its use over other corticosteroids.  In this case, the medical records fail to document the medical necessity of the requested Acthar Gel. 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 rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care was not medically indicated 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 anesthesiology 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 a wireless pressure sensor for evaluation of her medical condition.  Findings: Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested device.  Per the medical evidence, the efficacy of the requested device is uncertain at this time and is not recommended in current guidelines for the treatment of heart failure.  In this patients case, the requested wireless pressure sensor is not likely to be of greater benefit to this benefit than standard modalities. Final Result: Two reviewers determined that the requested device is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Opana ER for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  In the documentation available for review, non-opioid treatment options have not been exhausted.  The records do not document behavior therapy, despite research to support its use.  In addition, the records indicate that tolerance has taken place.  However, the providers long-term plan for treating tolerance has not been documented.  Dose escalation is not a long-term plan, but a short term plan for the treatment of tolerance.  The medical evidence suggests that opioid rotation or the use of long-acting opioids does not decrease pain tolerance or addiction any better than their counterparts.  The current medical evidence does not support the medication at issue in this clinical setting.  All told, Opana ER was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested dopamine transporter imaging with single photon emission computed tomography (DAT-SPECT) for evaluation of his medical condition.  Findings:  Two physician reviewers found that DAT-SPECT has utility in complex cases in differentiating between Lewy body dementia, essential tremor, and dementias.  In this particular case, the patient had a family history of Lewy body dementia and a history and examination notable for cognitive decline, a tremor, and some features of Parkinsons disease.  One clear etiology was not present by the patients history and examination.  In such cases, it is reasonable to obtain ancillary tests to help obtain an accurate diagnosis.  This limits trials of non-beneficial medications and potential side effects.  The lack of a proper diagnosis can lead to mismanagement of functional decline of a patient.  Therefore, DAT-SPECT was likely to have been superior over other methods of evaluating this patient. Final Result: Two 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:   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.