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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for treatment of the enrollees adenomyosis. Findings:  The physician reviewer found that MRI guided high intensity focused ultrasound ablation has been U.S. Food and Drug Administration (FDA) approved for treatment of fibroids, not adenomyosis. There is limited data on the use of magnetic resonance imaging (MRI) guided high intensity focused ultrasound ablation for patients with adenomyosis. In addition, Stewart and colleagues reported that studies are needed to determine long-term outcome and optimal candidates for this procedure; comparative studies are also needed. Further, the authors noted that the only guaranteed treatment for adenomyosis is total hysterectomy. This patient has requested MRI guided high intensity focused ultrasound ablation as treatment for her painful and heavy periods with a diagnosis of adenomyosis. This patient has not exhausted standard therapies for her condition. All told, the requested MRI guided high intensity focused ultrasound ablation is not 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 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that the physician reviewer found that this patient presented with increased coronary risk. In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, myeloperoxidase, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. All told, advanced lipoprotein testing was not likely to have been of greater benefit than other 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 internal medicine with sub-specialty certification in cardiovascular 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 internal medicine with sub-specialty certification in cardiovascular 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 three is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Achilles tendon repair surgery for treatment of the enrollee, who is status post right Achilles lengthening procedure. Findings: The physician reviewer found that the current, evidence-based, peer-reviewed literature generally supports surgical treatment for insertional Achilles tendinopathy for patients with ongoing pain and functional limitations who have failed conservative treatment. This patient presents with a complex right foot/ankle history with ongoing pain and functional limitations in mobility. Clinical examination findings have been consistent with imaging evidence of severe Achilles tendinosis/tendinitis. An orthopedic specialist recommended consideration of Achilles reconstruction with caution based on the patients surgical history, if the patient failed to improve with the conservative treatment recommended at his consultation. While the physical therapist documented the patient failed to improve with conservative treatment the patient has not subsequently been re-evaluated by the surgeon he consulted to confirm these findings as well as that the patient remains an appropriate candidate for Achilles tendon repair surgery. As such, re-evaluation with the provider who recommended the proposed Achilles tendon repair is medically necessary at this time. If the surgeon who previously recommended the surgery is unable to re-evaluate the enrollee, the enrollee should be evaluated by another orthopedic surgeon who is appropriately qualified to perform the enrollees Achilles tendon repair surgery if the surgeon deems it to be medically necessary. Final Result: The reviewer determined that re-evaluation by the surgeon the enrollee  previously consulted with or another appropriately qualified orthopedic surgeon is medically necessary at this time. Therefore, the Health Plans denial should be upheld at this time pending the surgical re-evaluation. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Botox for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that this patients provider documented more than 15 headache days a month for two months. Underreporting of headache frequency is typical as patients often only include the severe and disabling migraines, and do not mention the milder headaches that respond to medications like Excedrin. Botox is the only preventive medication approved by the U.S. Food and Drug Administration (FDA) for treatment of chronic migraine as demonstrated in the PREEMPT II trial. All told, the requested Botox is more likely to be effective than standard therapies for treatment of this patients chronic migraine. Final Result: All three 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 number one is board certified in internal medicine with sub-specialty certification 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 internal medicine with sub-specialty certification 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 internal medicine with sub-specialty certification 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 authorization and coverage for Xeljanz XR 11 mg daily for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the request for Xeljanz XR 11 mg daily is not medically necessary for treatment of the patients medical condition. According to the medical records provided for review, there is a lack of evidence demonstrating that the patient has had a trial and failure of at least two anti-tumor necrosis factor (TNF) agents. The Health Plans formulary alternatives including Enbrel, Humira, Remicade and Simponi are medically reasonable in this clinical setting. Given the lack of documentation supporting the failure of at least two anti-TNF agents, the request for Xeljanz XR 11 mg daily has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet for treatment of the enrollees pain. Findings:  The physician reviewer found that The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Absent a change in the fracture status or the development of complex regional pain syndrome, there is no indication for stronger opiates. The Centers for Disease Control and Prevention guidelines do not support ongoing opiates for chronic, non-malignant pain, such as in this case. The current medical evidence does not support the requested medication in this clinical setting. All told, Percocet 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Sovaldi 400 mg once per day and Ribasphere 600 mg twice daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. .Findings:  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, and advanced fibrosis is not required for treatment. However, per the guidelines, Epclusa is the only recommended 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 with ribavirin, without the adverse effects of ribavirin (Feld, et al; Foster, et al). Due to these trial results, Sovaldi and ribavirin are no longer recommended as first-line treatment for patients with genotype 2 hepatitis C. For these reasons, the requested Sovaldi 400 mg once per day and Ribasphere 600 mg twice daily for 12 weeks are not supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees melanoma. Findings:  The physician reviewer found that The physician reviewer found that melanoma is a cancer that is curable in its earliest stages. Cutaneous melanoma is initially treated by wide surgical excision and sampling of sentinel lymph nodes for those with high depth of invasion, 0.76-1.0 mm. Metastases to regional lymph nodes may be amenable to excision, but this suggests a high risk for the development of metastatic disease in the future. Such patients may be observed or treated with interferon-alpha.  The data on DecisionDx-Melanoma testing has not made it part of routine analysis after sentinel lymph node biopsy. There has also been some lack of consistency between various genes being used as biomarkers. As such, the test is novel, and it is unclear how best to incorporate it into the treatment algorithm beyond standard staging techniques. Thus, DecisionDx-Melanoma testing was not likely to have been more effective than 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for periodontal care, gum recession surgery, extractions, and orthognathic surgery nature for treatment of the enrollee who is status post repair of a cleft palate. Findings:  The physician reviewer found that there is a lack of support for the medical necessity of the requested services in this clinical setting. The patient does have periodontitis that will require dental treatment but that is not related to the patients cleft palate. The risk factors for periodontitis include amongst others poor oral hygiene. Treatment with scaling and root planning would be appropriate for the patient. Grafting the patients gingiva to augment her gingiva is also appropriate given the patients periodontal findings. However, the documentation provided indicates that the treatment of her periodontal condition is not related to the patients cleft palate. There is no documentation to support the need for orthognathic surgery. Per the notes provided, there are no issues with the patients repaired cleft palate. As such, periodontal care, gum recession surgery, extractions, and orthognathic surgery will not improve function. There is no documentation of any functional deficit from the patients malocclusion and no documentation to indicate any issues with the patients repaired cleft palate. This patients periodontal gum care are dental in nature and not a direct result of the patients cleft palate. Therefore, periodontal care, gum recession surgery, extractions, and orthognathic surgery are not medically necessary and are not reconstructive in nature for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary and are not reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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 of Lamictal for treatment of the enrollee who has a history of epilepsy. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the medical necessity of the requested medication in this clinical setting.  Several recent studies have examined the question of brand versus generic antiepileptic medication regimens. The medical literature that has compared common generic lamotrigine to the brand name Lamictal in patients with epilepsy showed that generic and brand bioequivalence are similar. The studies have shown that patient pharmacokinetic ratios support average bioequivalence public standard. A recent study performed also specifically looked at Lamictal and their study supports the evidence that the lamotrigine and Lamictal are bioequivalent when tested in patients with epilepsy. Additionally, the American Epilepsy Society Position states, The American Epilepsy Society (AES) recognizes that well-designed, prospective studies of generic antiepileptic drug (AED) substitution have been completed. Two studies demonstrated bioequivalence of generic products in patients with epilepsy taking concomitant AEDs. Additionally, an analysis of Abbreviated New Drug Application data suggests that generic products of branded modified-release products (e.g., extended release, delayed release) are bioequivalent and safely interchangeable. Results from these studies have shown no difference in bioequivalence when switching from a brand product to a generic product or between multiple generic products. In this patients case, this is the first time this patient will be taking Lamictal. The records do not indicate that the patient has tried a generic formulation of Lamictal. Based on the medical evidence and the documentation provided, Lamictal is not medically necessary for the 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 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.