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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein blood test (CPT 83704). This patient presents with hyperlipidemia and an elevated coronary calcium score. The provider noted that the patient was already being treated with active lifestyle modification and high dose statin therapy to lower his low density lipoprotein (LDL) cholesterol to goal per American Heart Association (AHA) and American College of Cardiology (ACC) guidelines (Grundy, et al.). Advanced lipoprotein measurements may be useful in patients with a borderline or intermediate 10-year risk of cardiovascular disease as part of a shared decision making regarding the need to start statin therapy (Arnett, et al.). In this case, the patient has known hyperlipidemia and elevated coronary calcium score. He was already being treated with a high dose statin per existing guidelines to appropriate treatment goals (Grundy, et al.). Further refinement of risk with advanced lipoprotein testing will not change the current management of active risk factor reduction with statin and lifestyle modifications (Arnett, et al.). All told, the advanced lipoprotein blood test (CPT 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Findings:  Three of the three physician reviewers found the advanced lipoprotein blood test (CPT 83704) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The 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 reviewers 1, 2, and 3 are board certified in internal medicine with subspecialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for compounded medications Estradiol 0.75 mg/gm and testosterone 1 mg/1 mL. The American College of Obstetricians and Gynecologists (ACOG) does not support the use of compounded hormone therapies for the treatment of hormonal imbalance. There is a lack of evidence demonstrating the safety and efficacy of compounded hormone preparations in lieu of U.S. Food and Drug Administration (FDA) bioidentical hormone therapies. There is a lack of large clinical trials that have determined the efficacy, safety, and adverse effects of estradiol and testosterone compounded preparations. A number of expert groups including the North American Menopause Society and the Endocrine Society have issued scientific statements advising against the use of custom-compounded hormones. Therefore, the compounded medications Estradiol 0.75 mg/gm and testosterone 1 mg/1 mL were not medically necessary for treatment of this patient. Final Result: The reviewer determined that the medications 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 obstetrics and gynecology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Orthovisc injection series for the right knee, and prospective authorization and coverage for Orthovisc injection series for the right knee.At issue in this case is whether the Orthovisc injection series for the right knee provided on specific dates and during a specific future period were and are medically necessary to treat the patients medical condition. An exhaustive review of the current medical literature pertaining to viscosupplementation reveals mixed results. Evidence from eight systematic reviews and six randomized controlled trials indicates that although viscosupplementation may relieve knee pain in some individuals with osteoarthritis, it is not known as to which individuals will benefit. Different studies have tried mixing hyaluronic acid with corticosteroids, platelet rich plasma, and other agents to make it more effective. The current evidence is limited, and guidelines from organizations such as the American Academy of Orthopedic Surgeons indicate that the evidence is not conclusive. In light of the foregoing, viscosupplementation can only be recommended in individuals with a history of lasting benefit from prior injections, and in carefully selected cases where everything else has been tried, and the options are limited. In this case, there is a history with viscosupplementation. Furthermore, the options are limited. The patient has tried and failed other treatments. Therefore, the Orthovisc injection series for the right knee provided on specific dates was medically necessary for the treatment of the patients medical condition. Additionally, the requested Orthovisc injection series for the right knee during a specific future period is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and 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 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 authorization and coverage for a motorized scooter (K0800 power operated vehicle, group 1 standard).Ornitz and Legeai-Mallet state that hypochondroplasia is caused by mutations in the gene encoding fibroblast growth factor receptor 3 (FGFR3). The clinical manifestations of these disorders include short stature, head/facial deformities, accentuated lumbar lordosis, limb shortening, hand deformities, and genu varum. The stature loss is primarily caused by limb shortening, with disproportionate involvement of the proximal limb segment, a pattern that is called rhizomelic limb shortening. Clinical manifestations may not be evident in early childhood. Potential treatment approaches for hypochondroplasia include use of recombinant human growth hormone therapy and surgical interventions for limb lengthening. In this case, the patient has hypochondroplasia, with short stature and short limbs. He has no focal neurological deficits and is ambulatory in the home without an assistive device. He was able to ambulate in the clinic independently, with good balance and without an assistive device when he was evaluated by physical therapy. A power mobility device has been proposed because it is reported that he cannot self-propel a manual wheelchair for long distances. However, a power mobility device for longer distance recreational travel is not a medical necessity. Therefore, a motorized scooter (K0800 power operated vehicle, group 1 standard) is not medically necessary to treat the patients medical condition.Final Result: The reviewer determined that the requested equipment  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 physical medicine and rehabilitation 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 N-acetyl cysteine.Kwo and colleagues state that there are multiple possible etiologies for elevated liver enzymes. According to Heard and colleagues, the use of N-acetyl cysteine (NAc) is recommended in an intravenous fashion for acute Tylenol overdose, generally starting within eight hours. Parvataneni and Vemuri-Reddy indicate that the use of NAc in non-acetaminophen-induced liver failure has also been reported, although it is not supported by clinical trials, and it is of marginal utility in acute liver failure from causes other than acetaminophen poisoning. In this case, the patient has had elevated liver enzymes in the setting of protracted alcohol abuse. The submitted records do not support acute liver failure, and a serologic or histologic workup for causes of liver disease has not been performed. For these reasons, N-acetyl cysteine is not medically necessary for the 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 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 authorization and coverage Aptiom and Banzel.Banzel and Aptiom are both approved by the U.S. Food and Drug Administration for the management of epilepsy. It is estimated that 20 to 40 percent of seizure patients have drug-resistant epilepsy. Trials of additional anti-seizure medications can be of benefit in individuals with drug-resistant epilepsy. According to Gilioli and colleagues, sequential drug trials can produce remission rates estimated at four to six percent per year, or a cumulative rate of 14 to 20 percent. According to Neligan and colleagues, 29 percent of patients with drug-resistant epilepsy in which drug changes were made had 50 to 99 percent improvement in seizure frequency. In this case, the patient has tried and failed multiple anti-epileptic medications. Additionally, the patient has kept his seizures under control with Banzel and Aptiom. Thus, Banzel and Aptiom are medically necessary for the treatment of the patients medical condition. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an autonomic nerve system function tilt table evaluation. Findings:  The physician reviewer found that support tilt table testing for patients as part of the overall evaluation of interactions between the autonomic nervous system and the cardiovascular system and for patients being assessed for postural tachycardia syndrome (POTS). In this clinical setting, the patient fits these indications. Therefore, an autonomic nerve system function tilt table evaluation is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Three of the three physician reviewers found the requested autonomic nerve system function tilt table evaluation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with sub-specialty certifications in cardiovascular disease and clinical cardiac electrophysiology and is actively practicing. Physician reviewers 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lenvima (10 mg daily dose) capsule therapy pack.There is a lack of support for the requested medication in this clinical setting. Lenvatinib has not been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glioblastoma. The use of lenvatinib for glioblastoma is not supported by major drug compendia, the National Comprehensive Cancer Network guidelines, or medical literature. In a phase 2 trial by Reardon and colleagues, patients showed modest benefit, but only after treatment with bevacizumab. In this case, the patient has been diagnosed with glioblastoma. The patient has not yet received bevacizumab or other treatments. Therefore, Lenvima (10 mg daily dose) capsule therapy pack is not medically necessary for the 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 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: An enrollee has requested authorization and coverage for phototherapy.Multiple studies have demonstrated favorable results supporting the use of phototherapy for the treatment of lichen planus. Phototherapy has been a well-accepted therapy for this condition. Iraji and colleagues conducted an unblinded, randomized trial of patients with generalized lichen planus and found a significantly better response in the patients who received phototherapy as compared with low dose prednisone. Complete responses were attained by 52 percent of patients in the phototherapy group versus 13 percent of patients in the steroid group. In this case, the patient presented with an itchy rash all over her body. Records show that her condition worsened, which prompted a biopsy of the rash. The biopsy confirmed that the patient had lichen planus. She was started on clobetasol propionate cream, which has been ineffective in treating her condition. The current medical evidence supports phototherapy in this clinical setting. Therefore, phototherapy is medically necessary for the treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Positron Emission Tomography (PET) with concurrently acquired computed tomography (CT) for attenuation correction and anatomical localization imaging; skull base to mid-thigh. Findings:  The physician reviewer found that The most accurate assessments of disease activity typically occur when previously abnormal studies are repeated on a serial and regular basis. Generally, the same method of assessment should be used over time. In patients with metastatic breast cancer, tumor response on PET/CT appears to be a superior predictor of progression-free survival and disease-specific survival than response on CT. In this case, the patient has had PET scans to monitor her disease with metastases limited to the bones. Records indicate that prior to the scan at issue, her last scan was over a year prior. Therefore, the PET with concurrently acquired CT for attenuation correction and anatomical localization imaging; skull base to mid-thigh provided on 3/18/21 was medically necessary for the evaluation of the patients medical condition.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 overturned.Credentials/Qualifications: The reviewer 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 patient has requested authorization and coverage for Verzenio 200 mg. Findings:  The physician reviewer found that mainstay of soft tissue sarcoma treatment is surgical resection. In this case, the patient underwent surgical resection with a pathologic diagnosis of de-differentiated liposarcoma, which suggests chemotherapy resistance. Currently, there are limited data on effective treatment regimens, but there are biological features that support novel therapeutic approaches. In liposarcoma, there is amplification of CDK4 that may make the tumors sensitive to CDK4 inhibitors such as Verzenio (Abbas Manji, et al.; Kim). Dickson and colleagues conducted a phase II trial of Verzenio in the treatment of 30 patients with dedifferentiated liposarcoma. The authors reported favorable progression free survival and objective tumor response with manageable toxicity. The authors previously endorsed palbociclib, a CDK4/6 inhibitor similar to Verzenio, in the treatment of well-differentiated or dedifferentiated liposarcoma. This patients provider considered palbociclib but selected Verzenio due to its more favorable toxicity profile. For these reasons, the requested Verzenio 200 mg is medically necessary for 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 medical oncology with subspecialty certification in 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: The patient has requested authorization and coverage for Stelara 90 mg every six weeks. This patient has symptoms consistent with active Crohns disease despite treatment with Stelara dosed at 90 mg every eight weeks. Her provider has recommended a dose increase to include 90 mg every six weeks. One large randomized controlled trial demonstrated the safety and efficacy for induction and maintenance of remission in patients with moderate-to-severe Crohns disease resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed (Sandborn, et al.). Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for one year (Kopylov, et al.). The mechanism of action in Stelara is different than that of anti-TNF medications, and the other medications which this patient has failed (Tuskey and Behm). Another study showed that a large proportion of patients were able to maintain response with Stelara dose escalation to 90 mg every four weeks (Kopylov, et al.). In this case, the patient has failed high-dose Remicade. She demonstrated disease symptoms on Stelara dosed at every eight weeks. The patients Stelara level on testing was unlikely to be sufficient to control her Crohns disease (Battat, et al.). Continued use of Stelara every eight weeks or a change to another medication may result in worsening disease control and potential complications. Given these findings, the requested Stelara 90 mg every six weeks is medically necessary for treatment of this patient. 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 subspecialty 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.