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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for edaravone for treatment of the enrollees amyotrophic lateral sclerosis. Findings:  The physician reviewer found that there are conflicting results relative to the effectiveness of edaravone in the treatment of ALS with some studies demonstrating no efficacy. Some of the available studies regarding the use of edaravone suggest some efficacy for those patients with recent diagnosis. The specifics of this case demonstrate that this patient has had slow progression of ALS for over five years. There is a lack of evidence to indicate the superior efficacy of this medication for treatment of patients with ALS. Therefore, edaravone (Radicava) is not likely to be more efficacious than the available options for treatment of this patient.  Final Result: All three reviewers determined that the requested medication is 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient received services for alcohol use disorder. The medical literature supports services at the least restrictive environment if available. The patient could have obtained treatment for her alcohol use disorder at a lower level of care. Groups and therapy addressing alcohol use disorder are available as outpatient treatment options and do not require an inpatient stay. Moreover, the patient did not have any signs or symptoms of an acute psychiatric episode rendering her dangerous or destructive to self or others or grave disability that would require an inpatient stay. The records do not indicate that this patient had exhibited signs or symptoms of alcohol withdrawal that would have required 24 hours of close monitoring. Additionally, clinical notes show that this patient was independently engaging in everyday activities, which supports the patients ability to function as an outpatient. The patient was not exhibiting agitated, psychotic or intentions for self-harm or harm to others. For these reasons, the residential treatment services were not medically necessary for the treatment of this 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 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 the compound medication levothyroxine sodium 100%, microcrystalline cellulose, liothyronine sodium 100%, capsule coni-snap and hypromellose for treatment of the enrollees hypothyroidism. Findings:  The physician reviewer found that the medical records fail to demonstrate the medical necessity of the requested medication compound in this clinical setting. The patients vitals appeared stable with a heart rate of 70 and blood pressure of 116/81. The patients body mass index was noted as 30.6. The records did not provide a clinical reason as to why this patient could not try preparations T4 and T3 as treatment options. The records do not indicate treatments or objective data to support the patients request for the medication compound. Therefore, the records provided have not established that the requested medication compound is medically indicated in this patients case.  Instead, preparations T4 and T3 should be tried as first line therapies in the treatment of this patients hypothyroidism. In sum, the compound medication levothyroxine sodium 100%, microcrystalline cellulose, liothyronine sodium 100%, capsule coni-snap and hypromellose is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication compound 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for low dosage Ketamine infusion for three to five days for treatment of the enrollees complex regional pain syndrome (CRPS). Findings:  The physician reviewer found that Connolly and colleagues performed a systematic review to examine and synthesize the available literature concerning the treatment of CRPS with Ketamine. The authors concluded that There is no high quality evidence available evaluating the efficacy of ketamine for CRPS and all manuscripts examined in this review were of moderate to low quality. Therefore, we conclude there is currently only weak evidence supporting the efficacy of Ketamine for CRPS, yet there is clearly a rationale for definitive study. In this case, the patient has undergone multiple outpatient infusions with subanesthestic doses of Ketamine and has had no lasting analgesic benefit. The request for three to five days ketamine infusion is not standard of care for CRPS as there is no evidence that such treatment provides long-lasting, durable pain relief. As such, the request for low dosage Ketamine infusion for three to five days is not likely to be more beneficial for the treatment of the patients medical condition than any available standard therapy.  Final Result: All three reviewers determined that the requested service is 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for Guardant360 gene testing for evaluation of the enrollees left-sided thoracic mass lesion. Findings:  The physician reviewer found that The Guardant360 gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient presented with suspected soft tissue sarcoma but no evidence of biopsy proven cancer. Molecular profiling with Guardant360 testing is used on patients with biopsy proven malignancies to help guide therapy decision making and is not indicated for every malignancy. Performing Guardant360 without biopsy proven disease is premature. Based on the clinical documentation submitted for review, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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: The enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 4aFindings:  The physician reviewer found that According to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment naive genotype 4 patients, based on the ASTRAL-1 trial, which showed 100% cure rate. Delay in treatment may result in decreased survival.  For these reasons, Epclusa 400-100 mg 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 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 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: The enrollee has requested authorization and coverage the LINX device and LINX procedure for treatment of the enrollees gastroesophageal reflux disease (GERD). Findings:  The physician reviewer found that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation provided for review the patient had a negative pH. On Day 2 of the ambulatory monitoring the patient had essentially no reflux. The patient was positive for the second day at 6.9% but this is not a high value. Manometry shows no hiatal hernia and a normal lower esophageal sphincter (LES) pressure. In addition, there is a lack of documentation indicating the patients medications tried and failed. Based on the clinical information provided for review, the LINX device and LINX procedure cannot be deemed 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 procedure is 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 reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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:The enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1bFindings:  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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens that include Zepatier for 12 weeks. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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 medication is medication 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for Vantas 50 mg kit implant for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that According to current medical literature, prepubertal suppressive therapy in pediatric patients diagnosed with gender dysphoria is not medically necessary. Medications have been used off label for pubertal suppression in gender dysphoric children including two that are approved for the treatment of precocious puberty: leuprolide by intramuscular injection and histrelin (Supprelin LA), a subcutaneous implant with yearly dosing. However, there are no available medications that have current U.S. Food and Drug Administration approval for suppressing physiologic hormonal development in pediatric patients with gender dysphoria. Through suppression of the hypothalamic pituitary axis, these agents prevent development of secondary sex characteristics, but also inhibit bone growth and interfere with estrogen- or testosterone-dependent brain maturation and inhibit fertility. Additionally, the American College of Pediatricians do not recommend prepubertal suppressive therapy in gender dysphoria patients. While this patient may have longstanding history of gender nonconforming behaviors, including statements of wanting to be a girl, there is a lack of support in the medical literature to support its use for prepubertal pediatric patients who are diagnosed with gender dysphoria. For these reasons, Vantas 50 mg kit implant is not medically necessary for treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 Humira Pen 40 mg/0.8 ml pen injection kit.Findings:  The physician reviewer found that that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has a history of generalized granuloma annulare.  Treatment of generalized granuloma annulare is difficult. The records indicate that this patient has tried and failed treatment with topical steroids, ultraviolet B therapy, methotrexate, and isotretinoin. Additional therapies for the treatment of granuloma annulare include hydroxychloroquine, chloroquine, dapsone, and cyclosporine.  As the standard first-line and second-line therapies have not been tried, and the requested medication has not been adequately studied in the treatment of granuloma annulare, Humira Pen 40 mg/0.8 ml pen injection kit 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for allergy testing for evaluation of the enrollee, who has a reported history of allergy to foods. Findings:  The physician reviewer found that The physician reviewer found that multiple evidence-based studies have demonstrated that IgG testing to foods is an unproven method of testing for food intolerances as well as food allergy. IgG antibodies are proteins produced by the immune system in response to exposure to external triggers, like pollens, foods or insect venoms. Their presence reflects exposure to these triggers, not disease that results from exposure. IgG antibodies to food are commonly detectable in healthy adult patients and children, whether food-related symptoms are present or not. There is a lack of credible evidence demonstrating that measuring IgG antibodies is useful for diagnosing food allergy or intolerance, or that IgG antibodies cause symptoms. The only exception is that gliadin IgG antibodies can be used to monitor the success of avoiding gluten in people with proven celiac disease.  In conclusion, testing for IgG to a panel of foods in this patient or any patient is not a standardized or recommended method of evaluating and treating a patient for suspected food allergy or food intolerance.  All told, allergy testing was not likely to have been superior over other available methods of evaluating this patient. Final Result: All 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: Physician reviewer number one is board certified in allergy and immunology 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 allergy and immunology 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 allergy and immunology 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.