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

Nature of Statutory Criteria/Case Summary: An enrollee requested a 12-week course of Zepatier for treatment of the enrollees chronic hepatitis C virus.  Findings: The physician reviewer found that according to the 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 treatment naive genotype 1b patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al). However, there are no controlled direct-comparison trials showing that Zepatier is safer or more effective than Harvoni for treatment of genotype 1 hepatitis C. Per the AASLD/IDSA guidelines; they cite data showing reduced survival with delayed treatment (Jezequel, et al). While treatment for this patients hepatitis C virus is medically necessary, the requested 12-week course of Zepatier is not medically necessary unless treatment with Harvoni is unavailable.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX esophageal sphincter augmentation device for treatment of the enrollees Barretts esophagus, hiatal hernia, and gastroesophageal reflux disease (GERD). Findings: Two physician reviewers found that there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). One peer-reviewed journal reported that there are 11 cases of endoscopically-confirmed LINX erosion through the esophagus in the FDA Adverse Events database (Bielefeldt). Additionally, LINX, more than surgical fundoplication, is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al). The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment including surgical fundoplication (Sheu, et al). Further, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX esophageal sphincter augmentation device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment 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 gastroenterology 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 Foundation One gene test for treatment of the enrollees glioblastoma.  Findings: Two physician reviewers found that the Foundation One gene testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not determined that molecular markers are useful in treatment determination and its use is not addressed for patients with glioblastoma multiforme, other than those with KRAS gene mutation. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy (NCI-MATCH: Targeted therapy directed by genetic testing in treating patients with advanced refractory solid tumors or lymphoma). As genetic testing to guide therapy is the subject of an ongoing phase II clinical trial, the Foundation One gene test has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for treatment 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 medical oncology and hematology 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 coronary computed tomography (CT) and the related services performed for the evaluation of the enrollees coronary risk. Findings:  Two physician reviewers found that this patient is diagnosed with type 2 diabetes and hyperlipidemia. The patients provider recommended a coronary calcium score with computed tomography (CT) scan to assist in the management of cardiovascular risk for this patient. The patient requested reimbursement for the coronary CT and the related services performed. The Health Plan denied the reimbursement as investigational for the evaluation of the patients coronary risk. While there are some studies related to the effectiveness of using a coronary calcium score as an assessment tool in this clinical setting, its superior efficacy over current standard modalities has not been established. The American College of Cardiology (ACC) does not give this test a Class I recommendation (should be performed). Instead, the ACC gives it a Class II recommendation (may be done or reasonable). As such, the ACC recommendation for this test, used in this clinical setting, does not carry the strength of a Class I recommendation. Therefore, in this patients case, the computed tomography (CT) and the related services performed were not likely to be more efficacious than the available standard tests for the evaluation of this patient.Final Result: The reviewer 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 upheldCredentials/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 coverage for high intensity focused ultrasound (HIFU) for treatment of the enrollees desmoid fibromatosis of the right breast and chest wall. Findings: Two physician reviewers found that the request for HIFU is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Wang and colleagues evaluated the feasibility, safety and therapeutic effects of HIFU in the treatment of extra-abdominal desmoid tumors. The authors concluded that HIFU could be used as an effective minimally invasive therapy for local control of extra-abdominal desmoid tumors. The patient presents with right breast desmoid fibromatosis extending into the chest wall and intercostal space. Surgery is not indicated due to the size and location of the right chest wall mass and a significant recurrence rate. In addition, treatment with radiation is likely to damage the lungs and the tumor invaded ribs and also preclude any type of possible resection in the future. The patient has failed chemotherapy twice with significant side effects. Thus, HIFU is a medically reasonable and appropriate in this clinical setting. Accordingly, the request for HIFU has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in interventional 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested autonomic function testing (CPT 95943) for evaluation of the enrollee, who has a history of lightheadedness and extreme sweating. Findings: Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient has had lightheadedness on standing, suggesting orthostasis.  Physical examination revealed a carotid bruit.  No orthostatic vital signs are documented.  Hyperhidrosis is commonly idiopathic, but can be symptomatic of many medical conditions, such as acromegaly, anxiety, cancer, medications, and hyperthyroidism amongst others.  Autonomic neuropathy can cause reduced sweating, and would be unlikely to cause focal palmar and plantar hyperhidrosis.  In this patients case, the clinical documentation is inadequate to suggest significant autonomic dysfunction.  The literature regarding the value of autonomic nerve testing regarding syncope or presyncope is mixed at best, with a lack of high quality, randomized studies.  The clinical notes do not document the need for autonomic testing in this case.  All told, autonomic function testing was not likely to have been of greater benefit than other methods of evaluating this patient.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 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 for testosterone enanthate for treatment of the enrollees primary hypogonadism. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient requires testosterone replacement for his primary hypogonadism.  Testosterone replacement is the treatment of choice, unless contraindicated.  In this patients case, the Health Plan has denied coverage for testosterone enanthate.  However, the Health Plan will cover testosterone cypionate as an alternative.  Testosterone enanthate is equivalent to testosterone cypionate. The Health Plans requirement that the patient try the alternative testosterone cypionate is medically appropriate.  There is a lack of data supporting testosterone enanthate as opposed to testosterone cypionate in this case.  Therefore, the requested testosterone enanthate is not medically indicated 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 15-year-old of enrollee has requested weekly for treatment of the enrollees behavioral problems.  Findings: The physician reviewer found that the records provided for review do not support the medical necessity criteria for 75 minute therapy sessions. The patient is a candidate for treatment in a less intrusive, less invasive level of care, and the Health Plans authorization for dialectical behavior therapy (DBT) is reasonable. There is a lack of clinical justification to suggest that 75 minute sessions would result in better improvement in symptoms over standard weekly therapy sessions and routine medication management. Thus, the requested weekly therapy for 75 minutes is not medically necessary for treatment of this patients behavioral health issues.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for percutaneous tibial nerve stimulation. Findings:  Three physician reviewer found that standard therapy, anti-muscarinic/cholinergic medications and behavior modification have both failed to resolve overactive bladder symptoms in this patients case.  The medical literature supports the services at issue in this clinical setting.  This patient had failed prior medical therapy.  At this time, no other noninvasive options show the degree of response for overactive bladder symptoms refractory to medication as percutaneous tibial nerve stimulation. Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers 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 breast reduction surgery for treatment of the enrollees bilateral breast hypertrophy. Findings: The physician reviewer found that this patient presents with well-documented symptomatic macromastia that has failed reasonable conservative management. Her examination and degree of resection planned are supportive of her clinical functional deficit. She would likely benefit significantly from breast reduction surgery. In addition, the American Society of Plastic Surgeons (ASPS) guideline states that reduction mammaplasty has been proven effective at reducing macromastia related symptoms and improving postoperative quality of life. Hammond and Loffredo noted that the presence of common symptoms related to strain on the upper torso attributable to the weight of the breasts must be documented. These symptoms can include headaches, neck pain, back pain, submammary intertrigo (particularly during the warmer months), painful bra strap marks with grooving and possible associated ulnar paresthesias caused by pressure on the brachial plexus, breast pain, difficulty wearing clothing that fits proportionately. This patient satisfies these criteria as there is evidence of well-documented, chronic back and shoulder pain and chronic intertrigo with failure of reasonable conservative management including analgesics and dermatologic treatment. Moreover, she has chronic headaches, evidence of chronic intertrigo with failure of dermatologic treatment and shoulder grooving as well. Her examination detail, planned degree of resection and review of the photographs are supportive of her significant macromastia. Based on this, her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. Furthermore, a 500-600 gram resection from each breast is consistent with a significant breast reduction. In summary, this patient has functional problems that are directly related to her significant macromastia. Breast reduction is a well-known procedure that will directly addresses this patients functional compromise. Thus, given the patients diagnosis of shoulder pain, intertrigo and macromastia, the requested breast reduction surgery is supported as medically necessary.Final Result: The reviewer determined that the requested surgery 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested the Growth Hormone (GH) therapy medication Humatrope 12 mg cartridge for treatment of the enrollees short stature. Findings: The physician reviewer found that the submitted documentation demonstrates the medical necessity of the requested medication.  This patient has extreme short stature and normal weight for height ratio, with an adult predicted height that is three standard deviations (SD) below the mean for adult standards in the United States. Although he has had normal growth factors, and GH stimulation testing has not been performed, this patient meets the Pediatric Endocrinology Society (PES) guidelines (Gharib, et al; Wilson, et al). Per PES guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two SD below the mid-parental height percentile; (2) growth velocity less than the  25th percentile for bone age; (3) bone age more than two  SD below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least three of the above criteria. Therefore, the requested Humatrope 12 mg cartridge is medically necessary for 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 pediatrics with sub-specialty certification in pediatric endocrinology 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.