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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication regimen.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  Per the guidelines, non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. The guidelines recommend either Harvoni or Zepatier as first-line therapy.  Of note, there is a need for NS5A resistance testing prior to Zepatier in genotype 1a.  The guidelines cite data showing reduced survival with delayed treatment.  Although treatment of hepatitis C is needed, the requested medication regimen, Harvoni for eight weeks, is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen, without trial and failure of Zepatier, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a 50-year-old female who was asymptomatic with respect to her breasts.  The patient had screening mammogram including digital breast tomosynthesis followed by whole breast ultrasound. There was no evidence of cancer. The Health Plan has denied the digital breast tomosynthesis portion of the examinations as investigational. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is evidence based support for the service at issue in this clinical setting. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies. Moreover, the studies have shown an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists when interpreting mammograms. Therefore, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective for the patient than had her examination been performed using two dimensional imaging alone. Final Result: 2/3 of the reviewers determined that  the service 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for celecoxib (Celebrex) one tablet two times per day for treatment of the enrollees right shoulder and neck pain. Findings:  The physician reviewer found that in the documentation available for review, the patient has both gastrointestinal risks as well as cardiovascular risks. However, the records do not document that the provider has weighed the gastrointestinal and the cardiovascular risks in regards to choosing which pain medication is appropriate for this patient. The current medical literature shows that Celebrex is not the best non-steroidal anti-inflammatory drug (NSAID) for patients that have both gastrointestinal and cardiovascular risk factors. Also, there is a lack of documentation of how the patient responded to treatment with ibuprofen, physical therapy, and acetaminophen. Moreover, there is no report of other non-NSAID considerations, besides acetaminophen, for treating pain in this patient that has gastrointestinal and cardiovascular risks. The literature states that for patients at risk for cardiovascular and gastrointestinal events, NSAID therapy should be avoided. In the absence of such documentation, the requested Celebrex one tablet two times per day is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for the enrollees breast cancer screening.  Findings: Three physician reviewers found that two dimensional digital mammography in the detection of breast cancer likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy in a routine screening. The patient has requested digital breast tomosynthesis but the Health Plan has denied authorization. Per the Health Plan, digital breast tomosynthesis was investigational/experimental for evaluation of the patient. The medical studies reviewed have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening.Final Result: Three reviewers determined that the service 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: All three physician reviewers are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollees breast cancer screening. Findings:  The 3 physician reviewers found that the patient is a female who presented for a bilateral screening mammogram with digital breast tomosynthesis. There was no mammographic evidence of malignancy. The patient reported a history of breast cancer in her mother. The current study noted her breast tissue was dense. The impression was benign. The Health Plan denied the request for reimbursement for the digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. The medical studies support the service at issue. According to colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Colleagues noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. The literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  As such, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  2/3 of the physician reviewers found that the patient is a female with positive family history of breast and ovarian cancer. She had screening mammogram including digital breast tomosynthesis which showed no evidence of cancer. The Health Plan has denied reimbursement of the digital breast tomosynthesis portion of the examination as investigational. There is evidence based support for the service at issue. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and biopsies and an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Thus, the addition of digital breast tomosynthesis to the usual two dimensional protocol was likely to be more effective to the patient than had her examination been performed using two dimensional imaging alone. Final Result: 2/3 of the reviewers determined that the  service 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 authorization and coverage for Saxenda for treatment of the enrollees obesity. Findings:  The physician reviewer found that the main goal of a weight loss regimen should be to decrease a patients cardiovascular risk. Therefore, pharmacotherapy can be added to lifestyle interventions in patients with a BMI of 30 kg/m2 or greater regardless of health history or those with a BMI of more than 27 kg/m2 and one additional cardiovascular risk factor, such as diabetes, hypertension, or hyperlipidemia. The approval of Saxenda followed several randomized controlled trials demonstrating its safety and efficacy in obese or overweight patients. This patient meets the criteria for addition of an anti-obesity pharmacological agent. Her BMI is over, she has comorbidities including hyperlipidemia and edema and has not lost weight with diet modification alone. Treatment should be made available early in the disease to prevent irreparable complications. Her provider has recommended Saxenda, which is appropriate based on the progress notes provided for review. For these reasons, the requested Saxenda is medically necessary for treatment of this patients obesity. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for real time remote heart monitoring services. Findings:  The two physician reviewers found that based on the records provided, this patient had a syncopal spell.  In this circumstance, an evaluation for a dysrhythmia was recommended by the treating provider to better assess the patient and identify a treatment plan. As such, a prolonged serial 48-hour Holter monitoring or off-line self-activated or auto-triggered cardiac event monitoring would have been sufficient in recording cardiac rhythm. There was no documentation to indicate this patient was not able to effectively manage the self-activated standard devices. There was no record to indicate that these devices have been tried and failed.  Some national organizations consider Holter monitoring and/or patient-activated or auto-triggered event recorders as appropriate initial tests and the standard of care for evaluation of dysrhythmias. As such, continuous real time monitoring by telemetry services are not likely to be more effective than the standard available monitoring devices. Off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety.  The current medical literature does not support that immediate recognition and reporting of dysrhythmias through a call center, provided by real time mobile telemetry services, improve health outcomes when compared to standard monitoring techniques.   Final Result: Two 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: All three physician reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested panitumumab (Vectibix) injection therapy for treatment of the enrollees metastatic colon cancer.  Findings: The physician reviewer found that as noted in the medical literature, cetuximab and Vectibix are monoclonal antibodies directed against the epithelial growth factor receptor (EGFR) protein on the surface of colon adenocarcinomas. Both medications have been demonstrated to be effective and safe in treating patients with colorectal cancer and are approved by the U.S. Food and Drug Administration (FDA) for use in metastatic colorectal cancer. Cetuximab is approved in combination with FOLFIRI as first-line treatment. FOLFIRI is an active regimen that has shown efficacy in stage IV colorectal cancer in combination with cetuximab or Vectibix (Peeters, et al; Van Cutsem, et al). Vectibix is indicated as a single agent after progression on fluoropyrimidines, oxaliplatin, or irinotecan-based therapies or in combination with FOLFOX as a first-line therapy. Peeters and colleagues reported increased progression-free survival in patients treated with FOLFIRI and Vectibix compared with FOLFIRI alone. Similarly, the PICCOLO trial also showed improved response and progression-free survival with Vectibix and irinotecan versus irinotecan alone in KRAS wild type tumors (Seymour, et al). Further, Van Cutsem and colleagues noted that in patients with markedly chemotherapy refractory disease, Vectibix and best supportive care was superior in terms of progression free survival with minimal toxicities when compared to best supportive care alone. For these reasons, the requested Vectibix is medically necessary for treatment of this patients metastatic colon cancer.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in oncology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested fentanyl patches for treatment of the enrollees post-laminectomy syndrome.  Findings: The physician reviewer found that based on the current medical literature and the presented clinical records, fentanyl patches are not medically necessary for treatment of the patients medical condition. The current standard of care for chronic pain associated with post-laminectomy is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. According to Mafi and colleagues Well-established guidelines for routine back pain stress conservative management including use of non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, and physical therapy, but avoiding early imaging or other aggressive treatments except in rare cases such as those demonstrating acute neurological compromise or other red flags such as a history of malignancy. In addition, Karppinen and colleagues state that Conservative decisions in the treatment of degenerative disk disease are based on interventions made for patients with chronic [lower back pain] LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. Moreover, high dose opioids are associated with a high risk of dependence. Therefore, the request for fentanyl patches is not 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 3. 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. The recommendations apply regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a 98% cure rate (Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, Epclusa 400/100 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.