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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for a gastroenterology consultation at a tertiary level facility. Findings:  The physician reviewer found that the records provided for review document that this patient has gastrointestinal disease consistent with inflammatory bowel disease, specifically fistulizing Crohns disease, although this has not been formally diagnosed. His course has been complicated by multiple surgeries and a need for intravenous antibiotics. Diagnosis and management of complicated inflammatory bowel disease, both medical and surgical, requires specialized expertise beyond that of a general gastroenterologist, which has been shown to result in better medical and surgical outcomes. Inflammatory bowel disease specialists at referral centers are associated with a lower risk of surgery. For these reasons, the requested referral to a gastroenterologist for consultation at a tertiary level facility is supported as medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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 Lyrica 150 mg capsules. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this patients case. Two separate articles have shown that pregabalin (Lyrica) is no better than placebo in pain relief for radicular pain. A study conducted a randomized controlled trial and did not find statistically significant differences in pain, disability, or patient satisfaction scores. Similarly, another study conducted a large, randomized, placebo-controlled trial with follow-up for 52 weeks. The authors found no reduction in pain in comparison with placebo and significantly more adverse effects with pregabalin. This medication is not likely to be efficacious for this patients pain. Therefore, Lyrica 150 mg capsules are not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rituximab for treatment of the enrollees thrombotic thrombocytopenic purpura. Findings:  The physician reviewer found that the physician reviewer found there is support for the requested medication in this patients case. TTP is a part of a class of diseases referred to thrombotic microangiopathies where dysfunction of the arteriolar/capillary endothelium causes uncontrolled microvascular thromboses by von Willebrand factor and platelets. Clinically, it manifests with thrombocytopenia, microangiopathic hemolytic anemia, acute kidney injury, purpuric rash, and central nervous system symptoms such as delirium. Von Willebrand factor is a major required factor for platelet aggregation. A deficiency of ADAMTS13, a metalloprotease that cleaves von Willebrand factor, is diagnostic of thrombotic microangiopathy when it is present in the context of all the other clinical signs. Acquired inhibitors are similar to the more common ones against factor VIII and develop due to several underlying diseases, such as cancer, systemic lupus erythematosus, postpartum, or drug reaction. The inhibitors are an autoimmune response that must be treated using immunosuppressive medications, such as corticosteroids and cyclophosphamide. Intravenous immunoglobulin and rituximab also work to lower inhibitor levels. Although the use of rituximab in thrombotic microangiopathy is off-label, there is sufficient published data to support its medical necessity in this clinical setting. All told, rituximab 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 internal medicine with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cambia oral powder for treatment of the enrollees migraines. Findings: The physician reviewer found that Cambia is an oral solution diclofenac. The records provided for review document that this patient was treated with Toradol and Imitrex without significant benefit. The patient was subsequently treated with Cambia with substantial benefit. In the medical literature, Joshi and Rapoport reported that diclofenac oral solution may offer rapid and sustained pain relief for patients who do not achieve pain resolution with other medications. In addition, patients who experience central sensitization with allodynia may benefit from the cyclooxygenase-blocking activity of diclofenac, which is needed in this advanced phase of migraine. Garnock-Jones noted that diclofenac potassium powder was clinically efficacious and generally well tolerated in placebo controlled trials and was more effective than diclofenac potassium tablets with regard to the primary endpoint of two hour pain relief as well as in several important secondary endpoints. Given that this patient has been treated with Imitrex and Toradol without benefit and Cambia was beneficial to improve headaches as well as improve function, the requested Cambia oral powder is medically necessary for treatment of this patients migraines.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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for removal of scar tissue in the intestine for treatment of the enrollees incisional post-operative pain status post total abdominal hysterectomy.  Findings:  The physician reviewer found that Based on the available documentation and current medical literature there is a lack of evidence that takedown of the adhesions will improve this patients abdominal pain. There is a paucity of data suggesting that abdominal scar tissue would cause this patients recurrent infections. Performing a scar tissue takedown will likely be more damaging than beneficial for the patient and will have the outcome of worsening the scar tissue and adhesions. Thus, the requested removal of scar tissue in the intestine is not supported as medically necessary for treatment of this patients medical condition. 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 thoracic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocortisone butyrate 0.1% ointment for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with history of psoriasis affecting the face. The patient is requesting hydrocortisone butyrate 0.1% ointment.  The Health Plan has denied the request as the requested medication is non-formulary and has authorized hydrocortisone 2.5% topical cream. The patient indicates that treatment with hydrocortisone 2.5% topical cream is not as effective as hydrocortisone butyrate 0.1%. However, there are other formulary options for treatment of the patients medical condition within the same steroid potency class as hydrocortisone butyrate 0.1% ointment. The records submitted for review do not demonstrate that the patient has not tried these agents. Moreover, while long-term use of mid-potency topical steroids on the face is best avoided due to potential side effects, approval of hydrocortisone butyrate 0.1% ointment does not avoid those implications. All told, the request for hydrocortisone butyrate 0.1% ointment has not been established as medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 151.66 hours per month of direct applied behavioral analysis (ABA) therapy and 28 hours per month with supervision for treatment of the autism spectrum disorder.Findings: The physician reviewer found that the request for 151.66 hours per month of direct ABA therapy and 28 hours per month of supervision provided were not and are not medically necessary for treatment of the patients medical condition. The Health Plans authorization of 121.3 hours per month of direct ABA therapy and 23 hours per month of supervision is medically appropriate and reasonable in this clinical setting. According to the documentation submitted for review, the patient has been meeting treatment goals, and has had a decrease of targeted behavior. In addition, the records do not demonstrate new problems or symptoms supporting the requested ABA hours requested. All told, the services at issue were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 pediatrics and neurology with special qualification in child neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for oxycodone for treatment of the enrollees cervical and lumbar spondylosis. Findings:  The physician reviewer found that in this case, the patient has not had a documented failure of a first-line long-acting opioid as the records available for review indicate that the only prior short-acting opioid medication trials have been Norco and Percocet. The patient has been maintained on Percocet 10 mg five times per day with minimal benefit of his pain complaints. Oxycodone ER is not a first-line long-acting opioid medication. The addition of oxycodone ER 20 mg is therefore 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  Three physician reviewers found that the medical evidence has not established the superior efficacy of the services at issue in this clinical setting. Per the submitted documentation, this patients HDL cholesterol is elevated, which suggests a lower risk for cardiovascular disease. The use of advanced lipoprotein testing for risk stratification remains of limited and questionable value in most clinical situations. Based on the clinical data provided, advanced lipoprotein testing is not recommended or indicated by current risk stratification guidelines. Thus, advanced lipoprotein testing provided was not likely to have been more effective than other methods of evaluating this patient. Final Result: 3 of 3 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for dopamine transporter single-photon emission computed tomography (DaT SPECT) scan. Findings:  Three physician reviewers found that while a DaT SPECT scan is not indicated for all patients with tremor, it has been shown to be useful when the diagnosis of Parkinsons disease versus essential tremor is suspected. These diseases can be challenging to differentiate based only on clinical grounds. In this particular case, the patient reportedly had findings consistent with both disorders. It is imperative to provide a definitive diagnosis, as treatment for Parkinsons disease and essential tremor are quite different, and placing the patient on a trial of therapy would place the patient at risk of significant side effects. In this particular case, the patients care was assisted by the use of this diagnostic study. Therefore, DaT SPECT scan performed was likely to have been of greater benefit than other modalities for evaluating this patient. Final Result: 2 of 3 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the gene test performed for evaluation of the enrollees breast cancer. Findings:  Two physician reviewer found that the decision regarding the use of adjuvant chemotherapy is generally based on the pathologic details of an individual patients breast cancer, as well as genetic analyses in certain situations. The most commonly used assay is Oncotype, though MammaPrint is also used as an alternative. There is good correlation between these genetic assays and prognosis, and both have been used as aids in the adjuvant chemotherapy decision. However, the BluePrint assay is not designed to predict prognosis but rather it defines what subclass of breast cancer, such as Luminal A, B or other. This determination is of interest, but not useful in making treatment decisions and has not been demonstrated to be clinically beneficial. Furthermore, in this case, the subclass is most likely Luminal A based on the pathologic details, thus additional testing for this determination was not indicated. Accordingly, the MammaPrint portion of the gene test performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the BluePrint portion of the gene test performed 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 a portion of 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 partially overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 patient has requested authorization and coverage for Supartz injections for treatment of the enrollees right knee osteoarthritis. Findings:  The physician reviewer found that  There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Maheu and colleagues conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Supartz injections are supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested service 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 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 Zepatier for 12 weeks for treatment of the enrollees hepatitis C. Findings: The physician reviewer found 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 for 12 weeks 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, Zepatier for 12 weeks 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.