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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Victoza for treatment of the enrollees diabetes, type II. Findings:  The physician reviewer found that according to the American Diabetes Association as to pharmacologic approaches to glycemic treatment, A patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, impact on weight, potential side effects, cost, and patient preferences.  Per the guidelines for glycemic targets, this patients diabetes control is not at goal of hemoglobin A1c 6.5-7%. The patient has tried Victoza and has experienced that this medication is the best treatment option for him. Victoza is a GLP-1 receptor analog, and has a mode of action that is more direct in mimicking the hormone GLP-1, which is deficient in diabetes. Additionally, Victoza has been shown to be more potent than Januvia, a DPP-4 inhibitor. However, while the medical literature supports the efficacy of Victoza for treatment of type II diabetes, Victoza is not to be used with Januvia. Januvia, like Victoza, is also an incretin based therapy. A clinical note documents that Januvia 100 mg tablet is one of the patients active medications. As such, the use of both medications is redundant and the medical studies do not support the use of these medications together. Therefore, while Victoza has been shown to be an effective treatment and appears to work better for this patient, Victoza is not medically indicated when Januvia is also being used. For these reasons, Victoza is not medically necessary for treatment of this 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 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: A 29-year-old female enrollee has requested authorization and coverage for surgery to make the abdominal wall tighter (abdominoplasty and suction assisted lipectomy) for treatment of the enrollees separation of abdominal muscles and excess skin and not reconstructive in nature. Findings:  The physician reviewer found that according to the American Society of Plastic Surgeons (ASPS), a true hernia repair involves opening fascia and/or dissection of a hernia sac with return of intraperitoneal contents back to the peritoneal cavity. A true hernia repair should not be confused with diastasis recti repair, which is part of a standard abdominoplasty. In addition, Townsend and colleagues noted that, the most common variant of normal anatomy seen in the abdominal wall is diastasis recti. This consists of an upper midline protrusion of the abdominal wall between the right and left rectus abdominis muscles. This abnormality represents a weakness of the linea alba and does not require treatment unless an epigastric hernia occurs in association with the diastasis recti. A review from Hickey and colleagues reported that, correction (of diastasis) is largely cosmetic, and although divarications may be unsightly they do not carry the same risks of actual herniation. Overall, plication of the rectus muscles is not established in the medical literature to be of functional benefit. In this case, the patients condition constitutes an abnormal structure of the body caused by pregnancy. However, the requested surgery is not likely to improve function or create a normal appearance to the extent possible. Abdominoplasty with diastasis repair is a body contouring rather than a functional procedure. Moreover, the requested surgery is not likely to provide more than a minimal improvement in the appearance of the patient. For these reasons, the requested surgery to make the abdominal wall tighter (abdominoplasty and suction assisted lipectomy) is not medically necessary or reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiation therapy for treatment of the enrollee who has a history of lung cancer. Findings:  The physician reviewer found that The requested services are not medically necessary for treatment of this patients medical condition. SBRT, delivering high fractional doses in 4-5 fractions, is an established approach for the treatment of discrete lesions from cancer. SBRT systems use fiducials, bony anatomy or external markers as a coordinate system to map the delivery of radiation to increase the precision and accuracy of radiation delivery. SBRT can be considered in select patients with oligometastatic bone metastases. Gerszten and colleagues and Harel and Zach outlined commonly accepted indications to include patients with good performance status, life expectancy greater than six months, no more than two contiguous sites involved and no direct cord compression. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is medically necessary when the patients performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks.  Bone metastases are discussed in this model policy as follows: SBRT has been demonstrated to achieve durable tumor control when treating lesions in vertebral bodies or the paraspinous region, where extra care must be taken to avoid excess irradiation of the spinal cord when tumor-ablative doses are administered. There is an important clinical distinction between the status of patients described above and a patient with widely metastatic disease for whom palliation is the major objective. In one setting, a patient with limited metastatic disease and good performance status is treated with the intention of eradicating all known active disease or greatly reducing the total disease burden in a manner that can extend progression free survival. For such a patient, SBRT can be a reasonable therapeutic intervention. However, in this patients case, the submitted documentation does not indicate that the ASTRO model policy criteria has been met as she has widespread disease. Therefore, SBRT is not medically necessary for 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 radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Doppler-guided transanal hemorrhoidal dearterialization for treatment of the enrollee who has a history of hemorrhoids. Findings:  2/3 of the physician reviewers found that THD is a technique used by colorectal surgeons as a treatment option for hemorrhoids. Multiple studies in support of THD have been recently published. For example, a recent systematic review and meta-analysis was published in 2015 by colleagues regarding the clinical outcomes and effectiveness of surgical treatments for hemorrhoids.  The review included 98 studies with 11 treatments for hemorrhoids and 7,827 patients.  The authors concluded that THD was associated with less postoperative bleeding and therefore, less emergency reoperations as well as decreased postoperative complications, shorter operative time, and decreased pain.  The authors concluded that the low cost of THD, low complication rate, shorter operating time and decreased levels of postoperative pain, but higher recurrence rate, may suggest THD as a safe, quick and easy initial surgical option.   In another study by colleagues, the authors concluded that THD is a safe and effective treatment of hemorrhoid disease. As such, the current medical evidence supports the efficacy of this treatment option for the treatment of hemorrhoids in patients who have exhausted conventional nonsurgical options. All told, Doppler-guided transanal hemorrhoidal dearterialization performed was likely to have been of greater benefit than other treatment modalities for the treatment of this patients hemorrhoidal disease. Final Result: 2/3 of 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 reviewer number one is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number two is board certified in surgery with sub-specialty certification in colon and rectal 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.Physician reviewer number three is board certified in surgery with sub-specialty certification in colon and rectal 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for consultation with an orthopedic surgeon for evaluation of the enrollees right hip pain with diagnosis of osteoarthritis. Findings:  The physician reviewer found that the records provided for review document that this patient has radiographic evidence of femoroacetabular impingement. She has chronic pain. There has been a failure of conservative treatment. Her activities of daily living are affected. As such, treatment is indicated. The indications for hip arthroscopy include the management of early osteoarthritis, synovial disorders, labral tears, chondral lesions, and femoral acetabular impingement which is increasingly recognized as a disorder that can lead to the development of early cartilage and labral injury. An orthopedic evaluation for this patient will determine based on the examination, imaging studies, and possible an intra-articular injection as to whether the pathology warrants additional diagnostic testing, and arthroscopy with surgical management. Conservative treatment has been tried and failed. In light of the foregoing, the requested consultation with an orthopedic surgeon is appropriate, reasonable, and medically necessary to manage the patients condition with regard to the hip pain. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: The parent of an eight-year-old male enrollee has requested authorization and coverage for 100 hours of direct one-on-one applied behavioral analysis (ABA) therapy (CPT code H2019), and 20 hours of supervision by Board Certified Behavior Analyst (BCBA) (CPT code H0032) for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that the documentation submitted for review does not support the need for additional hours of ABA therapy. The Health Plan had approved a block of ABA therapy that included provide 43.3 hours per month of direct one-on-one ABA therapy, 8.7 hours per month of BCBA supervision, and 4.3 hours of caregiver training. The ABA hours authorized by the Health Plan are medically reasonable in this clinical setting. According to the documentation submitted for review, the patients behavior does not pose significant threat of harm to the recipient or others. In addition, the gains made toward developmental norms and behavior goals can be maintained if care is reduced. Based on the clinical documentation submitted for review, the request for 100 hours of direct one-on-one ABA therapy (CPT code H2019), and 20 hours of supervision by BCBA (CPT code H0032) provided are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: A male enrollee has requested authorization and coverage of Stelara 90 mg/mL syringe administered every four weeks rather than every eight weeks for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that Current medical literature supports dose escalation of Stelara in this case. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of immunosuppressants and anti-TNF medications, both of which the patient has failed.  A study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks.  For these reasons, Stelara 90 mg/mL syringe administered every four weeks rather than every eight weeks is medically necessary for the treatment of this patients Crohns disease. Final Result: The reviewer determined that the requested medication dosage 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for actigraphy testing performed for evaluation of the enrollee, who reported a history of excessive daytime sleepiness. Findings: The 3 physician reviewers found that Circadian rhythm sleep disorders, such as delayed sleep phase syndrome, have traditionally been diagnosed on the basis of patient histories. Traditionally, sleep logs or sleep diaries have been utilized in clinical practice to record a patients sleep wake schedule.  In the past decade, actigraphy was developed as a technology, and it gained use in research studies and in some aspects of clinical practice. Colleagues published a study in which actigraphy and sleep logs were both utilized to evaluate patients with insomnia. The authors noted sleep diary parameters discriminated individuals with insomnia from good sleepers more accurately than actigraphy. Other studies have not shown that actigraphy is superior to patient reported/recorded values. In the clinical documentation provided for review, the patients self-reported sleep schedule was corroborated by the findings of his actigraphy study.  At this time, the literature has not established that actigraphy is more effective in establishing a diagnosis of a circadian rhythm sleep disorder than the use of sleep logs/diaries in adult patients who are able to maintain such record. Therefore, actigraphy testing performed was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 3 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 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.Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep 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 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: A male enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for treatment of the enrollees 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 (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, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Therefore, Harvoni 90-400 mg for eight weeks is medically necessary for the treatment of this patient.   Final Result: The reviewer determined that the requested medication regimen 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: A male enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus.Findings:  The physician reviewer found that according to the 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, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi (sofosbuvir) with ribavirin (Feld, et al; Foster, et al). Delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of the 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.