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

Nature of Statutory Criteria/Case Summary: enrollee has requested reimbursement for genetic testing. Findings:  Three physician reviewers found there is sufficient support for the services at issue in this patients case. The records indicate that the patient will fit the criteria for advanced maternal age at the time of delivery. Current recommendations include cell-free DNA testing as a viable option for all women after evaluation and counseling. Therefore, genetic testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: 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 reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Femring 0.1 mg. Estrogen is the most effective treatment for moderate to severe symptoms of vaginal atrophy. Vaginal atrophy causes bothersome vaginal symptoms commonly associated with menopause including vaginal or vulvar dryness, discharge, itching and dyspareunia. Local vaginal estradiol and local conjugated equine estrogen, which can be administered in cream, ring and tablet formulations, are effective in treating this condition. The results of randomized controlled trials show that even low-dose vaginal estradiol tablets can improve vaginal symptoms. Although studies indicate that the three-month estradiol-releasing vaginal ring is preferred to cream because of greater comfort, ease of use and satisfaction, there is also some data to suggest there may be a greater systemic absorption with this formulation. Because of variable rates of estrogen absorption associated with local estrogen therapy, there has been concern about the use of this treatment in women with a history of breast cancer. Since local estrogen treatment in the forms of creams, inserts and rings have all been found to be similarly effective in relieving the symptoms of vaginal atrophy, the patient can be treated with the Health Plans formulary alternatives including Yuvafem. In addition, given the patients history of breast cancer, it is prudent to choose the lowest dose preparation of local estrogen. For these reasons, the requested Femring 0.1 mg is not supported as 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 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: A 60-year-old female enrollee has requested reimbursement for the Helicobacter Pylori antibody test for evaluation of the enrollees abdominal tenderness.  Findings:  The physician reviewer found that the limited information provided there is no compelling reason to check the patients Helicobacter Pylori status. In this clinical setting, if the pain persisted, the standard recommendation is to perform an upper endoscopy and biopsy for Helicobacter Pylori. If a non-endoscopic approach is chosen, the recommended ways to detect Helicobacter Pylori are with urea breath test and stool antigen. Therefore, the Helicobacter Pylori antibody test was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the Helicobacter Pylori antibody test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Findings:  The physician reviewer found that an enrollee has requested authorization and coverage for Humira 40 mg/0.8 mL every seven days. This patient has had uncontrolled disease on dosing every 14 days. Researchers found that in the ULTRA 2 trial, it was part of the protocol to change patients to weekly Humira if response was not adequate on Humira every two weeks. In the ULTRA 3 trial, weekly Humira was started for inadequate response or for flare. Current guidelines recommend that when anti-tumor necrosis factor level is low, and anti-drug antibody is low or absent, the drug dose should be increased. Maintaining a dose of 40 mg every other week or changing to a different medication may result in disease flare, disease complications such as dysplasia leading to colon cancer, need for surgery, and hospitalization. For these reasons, Humira 40 mg/0.8 mL every seven days 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic testing.Findings:  Three physician reviewers found the medical evidence supports a portion of the services at issue in this clinical setting. Per the American College of Obstetricians and Gynecologists, screening for thrombophilias is not recommended for a history of pregnancy loss. However, since the patient reported that she is of Ashkenazi Jewish descent, screening for Tay-Sachs should be offered. There is support for Tay-Sachs screening during pregnancy if either member of the couple is of Ashkenazi Jewish descent. Therefore, Tay-Sachs screening was likely to have been more efficacious than other available methods of evaluating this patient. However, the superior effectiveness of MTHFR testing has not been established. Final Result: The reviewers determined that a portion of the services at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an minor has requested authorization and coverage for 112 hours per week of home health licensed vocational nurse (LVN) private duty nursing. Findings:  The physician reviewer found that the submitted documentation supports the requested services in this patients case. This patient has a number of problems as a result of and in addition to his myriad neurodevelopmental abnormalities. He requires suctioning as frequently as every 15 minutes, 24 hours per day. It is not safe or reasonable to expect his parent to perform such care to the exclusion of her other responsibilities. Private duty nursing services are thus medically necessary and appropriate for this patient. In sum, the requested 112 hours per week of home health licensed vocational nurse (LVN) private duty nursing are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). SBRT, delivering high fractional doses in four to five 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. The most recent American Society of Radiation Oncology (ASTRO) model SBRT coverage policy, reflecting national expert opinion, states that SBRT for metastatic lung, liver, adrenal, and kidney lesions is appropriate when the patients performance status justifies aggressive treatment, and for those whose tumor burden can be completely targeted with acceptable risks. Thus while this patient does not have oligometastatic disease, the need for SBRT has been established based on prior radiation and histology of the metastasis. Thus, the requested SBRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.One reviewer found that the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the requested services are 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:  One reviewer is board certified in radiation oncology and is actively practicing. One Reviewer is board certified in radiation oncology and is actively practicing.  One Reviewer is board certified in radiation oncology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for magnetic resonance spectroscopy. Findings:  Two of the three physician reviewers found that magnetic resonance spectroscopy is an imaging modality that has been used for evaluation the brain for various conditions. However, studies have produced mixed results. As per the treating provider, the lesion appeared more vascular in nature, and this decreases the utility of this study. The proximity to bone in this patient further decreases the utility and reliability of this imaging modality. There is a lack of evidence to suggest that magnetic resonance spectroscopy would have been superior over conventional MRI of the brain. Therefore, magnetic resonance spectroscopy was not likely to have been of greater benefit than other methods of evaluating this patient. 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 neurology 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 pembrolizumab (Keytruda). Pembrolizumab (Keytruda) is U.S. Food and Drug Administration (FDA) approved for the treatment of recurrent locally advanced or metastatic gastric or gastroesophageal junction adenocarcinoma in patients whose tumors express programmed death-ligand 1 (PD-L1), who have disease progression after two or more prior lines of therapy, including fluoropyrimidine-containing and platinum-containing chemotherapy, and if appropriate, HER2/neu-targeted therapy. The National Comprehensive Cancer Network (NCCN) guidelines recommend pembrolizumab for second-line therapy in patients with microsatellite instability-high (MSI-H) or deficient mismatch repair (dMMR) tumors or for third-line or subsequent lines in PD-L1 positive tumors. In this patients case, her mismatch repair (MMR) was proficient. This patient has not had PD-L1 testing or microsatellite instability testing. At this time, she does not meet criteria for treatment with pembrolizumab. Therefore, pembrolizumab (Keytruda) is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the single photon emission computed tomography (SPECT) scan. Based on the review of the records and evidence based research regarding use of SPECT scan for the patients condition, the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. It has been shown that SPECT imaging studies demonstrate selected areas that are affected by multiple drugs among substance abusers and can be useful to confirm specific diseases and clarify diagnosis wherein the clinical picture is not observed. However, in this case, there is no additional benefit for the SPECT scan as it was not expected to change the diagnosis or treatment plan. The use of SPECT scanning had no additional benefits compared to other available standard therapies available for this patients depression or substance use. Thus, the SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the SPECT scan 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 SPECT scan was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in psychiatry 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ExoDx Prostate Genetic Testing. The ExoDx urine exoxome genetic testing is available for men with elevated prostate specific antigen (PSA) to predict clinically significant prostate cancer. This testing is available in an attempt to avoid or proceed with prostate biopsy. However, prostate biopsy remains the most accurate diagnostic modality to detect prostate cancer. Furthermore, pathologic evaluation currently is the cornerstone to make prognosis regarding treatment options for prostate cancer. Therefore, the ExoDx Prostate Genetic Testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the ExoDx Prostate Genetic Testing provided 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 ExoDx Prostate Genetic Testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in urology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections in both knees. The current medical evidence supports the requested services in this clinical setting. Studies show that intra-articular hyaluronic acid provides a significant benefit in knee osteoarthritis. Studies show hyaluronic acid injections can reduce pain and increase function in patients with knee osteoarthritis. Studies show a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Studies show that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. There is sufficient support for the requested services in this patients case. Therefore, Euflexxa injections, in both knees is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 interferon alfa 2b injections. The submitted documentation supports the medical necessity of the requested medication. A large case series of 127 patients by researchers demonstrated an overall 54% response rate with a mean 9 degree improvement in curvature in all patients. The study concluded that intralesional therapy with interferon alfa 2b continues to be a viable treatment option for Peyronies disease with data consistently showing improvements in disease characteristics. The current medical evidence supports intralesional interferon alfa 2b for nonoperative treatment of Peyronies disease. Therefore, interferon alfa 2b injections is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in urology 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.