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

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient presents with persistent and worsening low back pain with functional difficulty in work and daily activities. Detailed evidence of at least six months of reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  However, there are no clinical objective findings of nerve root compromise correlated with imaging evidence of degenerative disc disease. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion is not medically indicated 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 orthopedic 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 Promacta for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication.   Immune thrombocytopenic purpura (ITP) is an autoimmune disorder where platelets are recognized by bodys immune system and eliminated. Platelet counts can decrease to very dangerous and life threatening levels. The standard course of therapy includes intravenous immunoglobulin (IVIG), steroids, rituximab, and anti-D. There are two newly U.S. Food and Drug Administration (FDA) approved thrombopoietin receptor agonists for ITP, Nplate (romiplostim) and Promacta (eltrombopag). Nplate is indicated for the treatment of ITP patients who have had an insufficient response to corticosteroids, immunoglobulin, or splenectomy. Additionally, Nplate should be used only in patients with ITP whose degree of thrombocytopenia and clinical condition increase the risk for bleeding. Eltrombopag has a similar indication. Per the prescribing information, Promatcta is indicated for thrombocytopenia in adult patients with ITP who have had an insufficient response to corticosteroids, immunoglobulins, or splenectomy. Thus far, this patient has not exhausted standard options such as IVIG, splenectomy, or rituximab. In the absence of failure of standard treatment options, the requested medication has not been established as medically necessary.   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 medical oncology and hematology 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 acute inpatient psychiatric services provided for treatment of his behavioral health condition.   Findings:  The physician reviewer found that according to the documentation submitted for review, the patient appears to have a medical disorder in context of a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses. He has multiple risk factors, and his particular condition is consistent with the conceptualization of grave disability. Prematurely discharging a patient under such circumstance would be inconsistent with contemporary practice standards, thus a conservative hospitalization was to be expected. Although formidable chronicity had declared itself, the patient was still gravely disabled. He remained engaged in active treatment services that were reasonably expected to prevent a worsening of his condition.  The inpatient team was adjusting a complex balance of multiple medications including a medication reserved for the most severe cases of his medical condition. The discharge planning team had not identified an appropriate treatment option in a less restrictive setting.  This is particularly important as his multiple hospitalizations and recent prompt readmission suggested a similar pattern moving forward in absence of a suitable step-down facility. Subsequently, the patients maintenance dose of medication had been established. He was appropriate in behavior and neither agitated nor disruptive. Further, he was accepted to an appropriate residential treatment program that could admit him. Considering his prompt decompensation that resulted in re-admission quickly after his most recent hospital discharge, retaining this patient at the inpatient level of care until direct disposition to the appropriate facility was in the best interest. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, the acute inpatient psychiatric services were safe, appropriate and consistent with good medical practice and that care could not have been reasonably delivered in a less restrictive setting until direct disposition to the appropriate facility.  Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Cosentyx for treatment of his medical condition.  Findings:  The physician reviewer found that the patient is requesting coverage for Cosentyx as treatment for his long-term plaque psoriasis.  He has had a trial of this medication which resulted in 100% clearance of his skin.  Over several years, the patient has already tried and failed therapy with topical steroids, ultraviolet B (UVB) phototherapy, and several medications.  It is not medically reasonable to require the patient to try and fail therapy with a biologic medication in the same class as another medication he failed prior to authorizing treatment with Cosentyx. Additionally, it is not medically reasonable that the patient be expected to repeat another trial of each of these medications prior to authorizing treatment with Cosentyx.  There is sufficient support for the requested medication in this clinical setting.  All told, Cosentyx 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 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 a positron emission tomography (PET) scan for evaluation of his medical condition.  Findings:  Two physician reviewers found that a PET scan is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. For pancreatic carcinoma, the standard radiographic work-up is generally ultrasound and then CT scanning.  Once metastases are discovered, the surveillance of the tumor is often sequential with CT scans to monitor the response to therapy. As in all tumors, PET scanning has become increasingly more popular. With regards to pancreatic tumors, a researcher states, The role of PET in the evaluation of possible sites of recurrence has yet to be determined. A small study of 20 patients including patients who had undergone the Whipple procedure, suggested that PET may be useful in clarifying equivocal CT examinations for recurrent disease. This is the critical issue in this patient, as there are no equivocal findings in this patients case.  There are clearly defined metastases which can be accurately measured. Finally, as stated by the National Comprehensive Cancer Network (NCCN) guidelines, PET/CT scan may be considered after formal CT pancreatic protocol in high-risk patients to detect extra pancreatic metastases.  It is not a substitute for high-quality, contrast-enhanced CT. For the reasons provided above, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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 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: 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: Three physician reviewers found that breast tomosynthesis provides advantages in this clinical setting.  In cases of extremely dense or heterogeneously dense tissue, the technique often enables the provider to separate dense glandular elements from underlying architectural distortion/mass thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  In sum, breast tomosynthesis performed was likely to have been of greater benefit than other modalities.  Final Result: Three 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials.  For these reasons, the requested treatment with Viekira Pak is medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Afirma gene test for evaluation of her medical condition.    Findings:  Three physician reviewers found that per the American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer, molecular testing has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The current ATA guidelines indicate For nodules with AUS/[follicular lesion of undetermined significance] FLUS 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. Informed patient preference and feasibility should be considered in clinical decision-making In this case, the patient had a cytopathology result consistent with FLUS. Without this test, the patient would have required a second biopsy or surgery to clarify the diagnosis. Therefore the submission of the specimen to Afirma gene expression classifier was appropriate. It was in benefit of this patient to have this test done more than other available standard therapy. All told, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.    Final Result: Three 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: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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 transcranial magnetic stimulation therapy for treatment of his medical condition. Findings: The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  In this patients case, anxiety dominates the patients phenotypic expression of distress, but an anxious-depression is present as well.  Despite the diagnosis of other depressive episodes, the records indicate that the patient meets criteria for a major depressive episode and thus the diagnosis of major depressive disorder.  The patients mood is lethargic, with a constricted affect.  His appetite is mood dependent.  The patient has poor energy, guilt, fatigue, sleep disturbance and negative thoughts and self-defeating schemas.  Further, the patient has tried many antidepressant medications and pursued psychotherapy.  Transcranial magnetic stimulation would be reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, the requested transcranial magnetic stimulation therapy is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested services 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 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 Nuvigil for treatment of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is no documentation of narcolepsy, idiopathic hypersomnia or shift workers sleep disorder.  There is no documentation of daytime hypersomnia from obstructive sleep apnea despite treatment with optimal CPAP.  There is no indication for Nuvigil.  All told, the requested medication Nuvigil 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Harvoni 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 1 regardless of fibrosis stage.  This patient is ineligible for the alternative for genotype 1a due to a pre-existing medical condition, which can be exacerbated by ribavirin.  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C 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 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.