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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including or Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Therefore, Zepatier 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast reconstruction surgery, lifting of breast implants for treatment of the enrollees breast cancer and not reconstructive in nature. Findings:  The physician reviewer found that as noted by the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Breast reconstruction is done to approximate a normal appearance and this includes complications related to breast reconstruction. Complications can occur following previous successful reconstruction. This patient has abnormal bilateral breasts as a result of a previously, severely deforming mastectomy and attempted breast reconstruction that is currently complicated by multiple deformities. The patient is documented to have continued breast deformities with ptosis, implant rippling and malposition. In addition, this condition is related to treatment of her right breast cancer and the requested surgery is aimed to produce relatively normal appearing breasts and is likely to provide more than a minimal improvement in the patients abnormal appearance. For these reasons, the requested breast reconstruction surgery, lifting of breast implants is supported as medically necessary and reconstructive in nature for treatment of this patients abnormal bilateral breasts status post mastectomy and attempted breast reconstruction. Final Result: The reviewer determined that the requested surgery is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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: An enrollee has requested authorization and coverage for positron emission tomography/computed tomography (PET/CT) scan for evaluation of the enrollees pelvic tumor. Findings:  2/3 of the physician reviewers found that this is a complex medical case involving a solitary fibrous tumor, which is an exceedingly rare tumor.  Considering the rarity of her diagnosis, there is little literature regarding the best means to perform follow-up imaging. However, PET/CT has several benefits over other standard modalities for the evaluation of patients tumor. One advantage to PET/CT is that, not only are masses demonstrated, but there is information garnered by the fludeoxyglucose PET/CT avidity in those masses.  As has been shown in patients with Hodgkins disease, on occasion, one will see a residual mass that is no longer FDG avid. Another advantage of PET/CT scans is that the entire body is scanned simultaneously.  To perform follow-up with routine CT scanning, one would have to perform CTs of the neck, chest, abdomen, and pelvis.  The same issues would occur with MRI scans. In summary, considering the question of changing chemotherapy, and the need to assess disease progression, PET/CT scans are the most accurate means to follow this patient.  Accordingly, PET/CT is likely to be superior to other methods of evaluating this patient.  Final Result: 2/3 of the reviewers determined that the requested services are 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 teriparatide (Forteo) for treatment of the enrollees osteoporosis.Findings:  The physician reviewer found that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and older. Of those affected, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis, which can lead to acute and chronic pain as well as increased mortality. Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including oral bisphosphonates.  Newer treatment agents have become available over the past few years, including Forteo, which is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone. Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has severe osteoporosis and is at high risk for a fracture. As this patients provider noted, treatment with Forteo may promote an increase in her bone mineral density, whereas prior treatment with a bisphosphonate may actually diminish or delay the efficacy of Forteo. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the carotid duplex scan for evaluation of the enrollees chest discomfort, hyperlipidemia, dizziness, and a strong family history of coronary artery disease. Findings:  The physician reviewer found that the records provided for review indicate that this patient did not have carotid bruit or focal transient neurological symptoms. Guidelines of the American College of Cardiology (ACC) and other sponsoring organizations do not support the use of duplex ultrasound imaging for dizziness such as recorded for this patient. Given the lack of support for the study in this clinical setting, the carotid duplex scan performed was not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the service at issue was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ibrance for treatment of the enrollee, who has a history of breast cancer. Findings:  The physician reviewer found that first line therapy for metastatic breast cancer is dependent upon the presence or absence of estrogen/progesterone receptors and/or HER2. Patients with metastatic breast cancer often respond to endocrine therapy, and newer treatment options appear to prolong progression and possibly survival. In this case, the patient has received letrozole and progressed while on it. Therefore, alternate therapeutic options should be considered. Palbociclib is a CDK4 inhibitor. In a study, it analyzed the role of palbociclib (Ibrance) and fulvestrant compared to fulvestrant and placebo. This study demonstrated that the combination resulted in an improvement in progression free survival. Based on current guidelines and the results of a well conducted study, the use of Ibrance in this patients case is medically necessary. 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 partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in hematology and 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 reimbursement for a carotid duplex scan for evaluation of the enrollee, who had a history of supraventricular tachycardia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient presented with symptoms of dizziness.  However, there were no focal neurologic symptoms, no known carotid stenosis, and no documented carotid bruit.  Thus, the records do not document indications for a carotid ultrasound to be performed.  The medical evidence does not support the services at issue in this clinical setting.  All told, the carotid duplex scan performed was not medically necessary for the evaluation of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene testing for evaluation of the enrollee who has been diagnosed with malignant melanoma. Findings:  2/3 of the physician reviewers found that FoundationOne testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers that can help guide therapy decision making. Per the National Comprehensive Cancer Network guidelines, it has not been determined if molecular markers are useful in treatment determination (predictive markers) and prognosis for other than BRAF and c-KIT mutational analyses which are clinically useful only for patients with advanced disease considering these molecular targeted therapies. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. As FoundationOne provides genetic testing to guide therapy and this is the subject of an ongoing phase II trial, the gene testing would be considered investigational/experimental for this patient. Accordingly, the gene testing performed was not likely to have been more effective than the other options of evaluating this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were not likely to have been 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 Otezla for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that this patient presents with chronic plaque psoriasis affecting 5% of his body surface area (BSA). He has tried and failed therapy with topical steroids and tanning booths. The medical records indicate the patient has a history of diverticulitis. However, there is no data provided to indicate that the patients diverticulitis is active or ongoing. While immunosuppressive agents are not indicated during active infections, the records provided at this time do not give enough details to determine whether the patient has ongoing infections requiring continuous treatments. As there is a lack of evidence for contraindication of usage of the preferred formulary agents, the request for coverage of Otezla is not supported as medically necessary for treatment of this patients plaque psoriasis. 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for perineorrhaphy and surgical repair of the vagina for treatment of the enrollees recurrent perineocele. Findings:  The physician reviewer found that based on the available documentation, specifically the providers notes, the patient continues to have a bulge in the perineum consistent with weakness in the area of the perineal body/distal rectum. This leads to persistent need for splinting to defecate associated with narrowing of the vagina and resulting dyspareunia. Given the patients persistent symptoms, further evaluation and surgical management of the patients persistent symptoms is considered a safe and appropriate next step. Thus, the requested perineorrhaphy, using the procedure recommended, surgical repair of perineocele, using the procedure recommended, and surgical repair of the vagina, using the procedure recommended is supported as medically necessary for treatment of this patients recurrent perineocele. 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the continuous passive motion (CPM) for treatment of the enrollees right hip pain.  Findings:  The physician reviewer found that according to the current medical literature, the CPM device provided to this patient was not medically necessary. Given the outpatient nature of the patients treatment, the standard of care would be for the patient to start outpatient physical therapy. The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol of rehabilitation following hip arthroscopy or any other hip procedure. Thus, the CPM provided was not medically necessary for treatment of this patients right hip pain.  Final Result: The reviewer determined that the device at issue was 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.