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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma gene expression classifier for evaluation of his thyroid nodule. Findings:  Three physician reviewers found that while FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma thyroid FNA analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy. As the Afirma gene expression classifier is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude unnecessary surgical procedures. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 reimbursement for carotid duplex scan performed for evaluation of the enrollees screen test. Findings: The physician reviewer found that according to the records provided, this patient did not have clinical signs of carotid disease including a lack of bruit. Moreover, there was no clinical history to indicate transient ischemic attack or neurological deficit. There is a lack of support in the documentation for the services at issue. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 and prospective authorization and coverage for residential treatment center services forward. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue. On the date of dispute the patient had mild post-acute withdrawal symptoms with a low CIWA of 5, and he was medically and psychiatrically stable. Regarding emotional, behavioral, and cognitive factors, he remained highly anxious and required medications as needed. He was behaviorally appropriate and cognitively intact. However, he was described as having no coping skills and requiring education. He had never been to meetings or had contact with any type of treatment at any level of care. His drinking had escalated since high school, essentially for the past seven years since age 18, to the point of drinking a fifth a day. He drives while intoxicated and blacks out, creating hazardous situations for himself and others. He had no sober support. These factors made for a very high risk for relapse. Residential treatment afforded medically appropriate services so that he could develop a modicum of coping skills and identify relapse triggers. Residential services also provided him with exposure to a 12-step program and with contacts to take with him into the community. Therefore, residential treatment center services from date of dispute for  three days were medically necessary but not thereafter.Final Result: The reviewer determined that the services at issue was 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 with sub-specialty certification in addiction 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: An enrollee has requested authorization and coverage for lumbar multilevel fusion for treatment of the enrollees back pain. Findings:  The physician reviewer found that the medical literature recommend surgery for spinal stenosis in patients who do not improve with conservative treatment. Numerous studies have demonstrated the role of surgical decompression in this patient population. However, few have investigated the utility of fusion in patients without underlying instability. The inclusion of fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. This patient presents with a history of chronic low back pain radiating into the right lateral hip and anterolateral leg with occasional numbness and tingling in the L4-5 distribution. Signs and symptoms are consistent with neurogenic claudication. Functional difficulty is documented in activities of daily living and work activities. Clinical examination findings did not evidence a focal neurologic deficit consistent with imaging evidence of L4-5 degenerative disc disease with severe bilateral neuroforaminal narrowing and moderate right lateral recess stenosis. Evidence of long-term conservative treatment, including analgesic medication, activity modification, and physical therapy, is documented without sustained improvement. However, there is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. There is no discussion supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Overall, the requested multilevel lumbar fusion is not supported by the submitted clinical or imaging records. Final Result: The reviewer determined that the requested surgery 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bowel retraining therapy without biofeedback for treatment of his severe outlet constipation. Findings:  The physician reviewer found that there are a number of causes for obstructed defecation syndrome and pelvic floor dysfunction such as rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidocele, or enterocele. Some of these are structural anatomical issues, but others are functional issues with normal anatomy. Bowel retraining therapy can be effective, and should be attempted before any more invasive intervention is considered. Unlike biofeedback therapy, bowel and pelvic floor retraining are easily translated into activities of daily living because the sensory cues of biofeedback therapy are not applied in training. In this case, the test confirmed a functional component to the patients outlet constipation. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for OxyContin 80 mg and oxycodone 30 mg (three times per day). Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. Providers should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 or greater MME per day, and should avoid increasing dosage to 90 or greater MME per day or carefully justify a decision to titrate dosage to 90 or greater MME per day. In the documentation available for review, no objective treatment goals for pain and function are noted for this patient to continue on the requested medications. The patient was recently taking 360 MME per day. However, no medical evidence based rationale is given for such a high dose. There has been no difference in pain scores or objective function despite decreases in the amount of opioids. Specifically, there is no improvement or change in the patients objective function with the 135 MME per day decrease. Further, no objective goals with this high of a dose of opioid has been established by the provider and increases appear to have been based on pain levels. The records suggest that tolerance has taken place since the start of the narcotics. There is also the concern for opioid induced hyperalgesia. Finally, not all non-opioid medications classes have been tried or optimized. For these reasons, the requested OxyContin 80 mg and oxycodone 30 mg (three times per day) are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications 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 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: A 31-year-old female enrollee has requested authorization and coverage for Port-A-Cath placement. Findings : The physician reviewer found that the medical literature does not support the medical necessity for the requested services in this patients case. The treatment plan indicated therapy with IVIG. However, there is no documentation of failed peripheral intravenous placement. Moreover, the record provided does not show that this patient is going to require treatment with IVIG long-term or that she has inadequate peripheral venous access. Additionally, the medical literature does not support that IVIG is caustic to the veins requiring central line placement in the form of a Port-a-Cath. As such, Port-A-Cath placement 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 internal 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: An enrollee has requested surgical intervention for 1 cm colloid cyst of the third ventricle in the brain for treatment of the enrollees colloid cyst. Findings:  The physician reviewer found that this patient has chronic headaches. Imaging found a foramen of Monro lesion consistent with a colloid cyst. She has maintained a normal neurological examination and an unchanged MRI scan. She has been advised nonsurgical management for her incidental colloid cyst brain tumors by two neurosurgeons and a third neurosurgeon recommended surgical treatment. Colloid cysts are rare brain tumors found on routine imaging and generally incidental findings. Medical nonsurgical management is considered the standard of care. Surgery is indicated for increased growth of lesions, if ventriculomegaly is seen on follow-up studies, if transependymal cerebrospinal fluid migration is noted, or the sulci are effaced. In this patient, there is no increase in size of the lesion, no hydrocephalus or ventriculomegaly, no transependymal migration of cerebrospinal fluid, and the sulcal pattern is unchanged. Final Result: The reviewer determined that the requested surgery 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 neurological 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 skilled nursing facility (SNF) services including physical rehabilitation for treatment of the her stage IV breast cancer. Findings:  The physician reviewer found that in the documentation available for review, this case illustrated the importance for clear communication and involvement of palliative and hospice care services as soon as possible. It is well known in the literature that physical and occupational rehabilitation therapy with patients in end stage cancer care is helpful with their overall condition as well as their quality of life. In this case, continued rehabilitation is indicated and appropriate. However, the need for those rehabilitation efforts to be performed at a SNF is not supported as medically necessary. The patients spouse acknowledged the difficulty of rehabilitation efforts while the patient was at the SNF. Thus, home hospice rehabilitation therapy should be continued. In addition, being allowed to pass in the familiar setting of ones own home does bring the greatest satisfaction both to the one dying and to the loved ones by their side. 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 anesthesiology with sub-specialty certifications in pain medicine and hospice and palliative care 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 Esbriet for treatment of the enrollees idiopathic pulmonary fibrosis.  Findings:  Two physician reviewers found that the medical literature supports the efficacy of Esbriet in this clinical setting. This patient has moderate to severe reduction in air volume with a forced vital capacity (FVC) measured at 55% and total lung capacity (TLC) of 51%. These outcomes are indications for treatment of IPF. The provider noted that this patient is intolerant to Ofev due to diarrhea, a common side effect reported in 62% of patients (versus 18% with placebo) in reported trials. After stopping Ofev, this patient should be allowed to begin Esbriet given her significant reduction in lung function which has continued to decline over the past year. Given this patients side effects with Ofev the requested medication Esbriet is an effective treatment option for this patient. The medical literature suggest that there are very few proven alternatives for treatment of this patients medical condition.  Final Result: The reviewers determined that the requested medication 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: Reviewer 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in pulmonary 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 Norco 10-325, three times per day, 10 tablets daily, and tizanidine 4 mg, two times per day or as needed for treatment of the her chronic pain.  Findings:  The physician reviewer found that this patient has requested continuation of her opiate therapy because she is in pain even though she has been informed of the risks of chronic opiate therapy in the setting of morbid obesity.  She has not participated in recommended alternative therapy. There is no evidence of an opiate maintenance agreement in the records submitted for review.  The Centers for Disease Control and Prevention has published a clinical practice guideline for prescribing opiates for chronic non-malignant pain. The request for continuing her pain medication would be counter to the practice guideline. Similarly, her morbid obesity constitutes an ongoing risk factor for respiratory depression in conjunction with her use of the muscle relaxant. Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer 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: An enrollee has requested authorization and coverage for brand name Xanax and Zoloft for treatment of the enrollees behavioral health issues. Findings: The physician reviewer found that according to the U.S. Food and Drug Administration (FDA), drug products are considered pharmaceutical equivalents if they contain the same active ingredient(s), are of the same dosage form, route of administration and are formulated to contain the same amount of active ingredient, and to meet the same or compendial or other applicable standards including strength, quality, purity, and identity. The drug products may differ in characteristics such as shape, scoring configuration, release mechanisms, packaging, excipients such as colors, flavors, preservatives, expiration time, and, within certain limits, labeling. Drug products are considered to be therapeutic equivalents only if they are pharmaceutical equivalents for which bioequivalence has been demonstrated, and they can be expected to have the same clinical effect and safety profile when administered to patients under the conditions specified in the labeling. Both Xanax and Zoloft are found in the FDA Orange Book and are listed as alprazolam and sertraline, respectively. Thus, the generic forms of these medications would be no different in bioavailability and efficacy than the brand versions. The provider in this case noted the patients recent decompensation does not coincide with a switch from brand to generic, as the patient has been on this same generic version of sertraline and alprazolam for several years. From pharmacy records provided, it does not appear that different manufacturers were used for either of these generic medications. In addition, the worsening of the patients condition, either situational in nature or otherwise, was not described. Final Result: The reviewer determined that the requested medications 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 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 Qudexy XR 100 mg for treatment of chronic pain. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The use of topiramate extended release (Qudexy XR) for this patients pain is an off-label use.  Clinical reviews of its efficacy and outcome have failed to showed benefit when compared to placebo in randomized controlled trials. She also did not receive benefit from the immediate release version of the drug and sustained significant side effects, including nausea, dizziness, loss of appetite and blurred vision.  There is a lack of support for the requested medication in this clinical setting. Final Result: The reviewers 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.