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

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the inpatient hospitalization services provided from 8/30/17 through 9/1/17 for treatment of the enrollees acute on chronic cholecystitis. Findings:  The physician reviewer found that Acute cholecystitis can be managed with cholecystectomy as a day surgery procedure, or with a short observation stay. The records provided for review document that this patient did not have protracted hypotension, tachycardia, or other signs of severe volume depletion or sepsis. Imaging performed just after presentation was not consistent with pathology such as biliary obstruction, gallbladder perforation, pancreatitis, or complications of gallstone disease. Additionally, the patient did not have acute cholangitis, active gastrointestinal bleeding, gastrointestinal perforation, peritonitis, abscess, sepsis, or other gallbladder or biliary complications warranting inpatient level of care (Tang, et al; Wilkins, et al; Macaluso and McNamara). She was appropriately evaluated for gallbladder disease, and her disease was fully addressed with laparoscopic cholecystectomy, which could have been performed without the inpatient level of care. For these reasons, the inpatient hospitalization services provided from 8/30/17 through 9/1/17 were not medically necessary for the treatment of the patients acute on chronic cholecystitis. Final Result: The reviewer determined that the services at issue were 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 reimbursement for gene testing (gene expression profiling) for evaluation of the enrollees cutaneous melanoma. Findings: The physician reviewers found that the gene testing (gene expression profiling) performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The National Comprehensive Cancer Network (NCCN) guidelines indicate that genetic testing such as the DecisionDx-Melanoma gene assay should not be used outside of a clinical trial setting. The use of gene expression profiling is not considered to be standard of care in the treatment of the patients melanoma. Thus, its usage is not expected to impact the treatment or health outcomes. All told, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in dermatology 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 advanced lipoprotein testing for evaluation of the enrollees abnormal glucose.Findings: All three physician reviewers found despite some providers advocating for use of the advanced lipoprotein analysis, the American College of Cardiology (ACC) guidelines do not support use of the advanced lipid testing. Rather, their guidelines recommend use of standard risk factors and lipid profiling to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. These guidelines are formulated based on thorough review of current literature. All told, the advanced lipoprotein testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ketamine infusion. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services. There were no medical records/progress notes from the provider, nor were there any individual psychotherapy notes. There was no record of the duration of each of the antidepressants listed, dosages, or any combinations that might have been used.  Furthermore, it is not known if dose optimization occurred in any of the medications tried.  There is no discussion in records provided, and no conclusion can be drawn, that the patient suffers from treatment-resistant depression.  If that were in fact the case, and all the above medication scenarios had occurred, the next step would be a discussion of electroconvulsive therapy, which remains a highly effective treatment for patients with treatment-refractory depression. Thus, the requested ketamine infusion is not likely to be of greater benefit than other available treatment options. Final Result: 3 of 3 reviewers determined that the requested services are 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 psychiatry and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2a/c. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). For these reasons, Epclusa 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Guardant360 blood test provided for evaluation of the enrollees gastric adenocarcinoma. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Guardant360 testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Guardant360, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is insufficient to support the use of Guardant360 in lieu of standard testing. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Guardant360 test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for excess skin removal procedures for stomach and thighs for treatment of the enrollees excess skin and not reconstructive in nature. Findings:  The physician reviewer found that The requested panniculectomy is not medically necessary for treatment of this patients medical condition. The medical records do not provide any documentation of an ongoing clinically significant dermatologic problems that have either never responded to physician directed topical therapy or despite initial response, have recurred and caused significant functional impairment. Overall, supervised medical management for rashes is not documented in any of the progress notes. Further, the patient is not sick from her excess skin, and has not had ulcerations, panniculitis or sepsis from her infections. A dermatologist has not reportedly evaluated the patients rashes and the patient has not required hospitalization or treatment with intravenous or oral antifungal or antibiotic medications. As noted in the medical literature, medically supervised treatment is the most appropriate method for managing this patients problems, and conservative treatment with appropriate hygiene and topical medications has a reasonable likelihood of correcting the condition. In a multiple regression analysis of postoperative complications after body-contouring surgery written by Parvizi and colleagues, the authors found that the overall rate for major complications that required operative revision and/or antibiotics was 10.2%. In addition, 41% had minor complications, such as seromas, hematomas, wound healing problems, and wound dehiscences. Therefore, conservative, non-operative treatment is recommended, such as improved hygiene, topical creams or powders, and watchful waiting. Surgical lipectomy is reserved for patients that have failed optimal medical management for intertrigo, which is not documented to be the case for this patient. In addition, the patients condition does not constitute an abnormal structure of the body as an abdominal pannus is an expected consequence of weight loss. Moreover, the requested surgery is not likely to provide more than a minimal improvement in the patients appearance. Thus, the requested panniculectomy is not reconstructive in nature or medically necessary.Final Result: The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the lumbar spine magnetic resonance imaging (MRI) for evaluation of the enrollees bilateral leg pain and burning. Findings:  The physician reviewer found that the review of the records provided for review demonstrates that the patient did not report any antecedent trauma. In addition, the provider did not note any concern for infection or metastatic disease. The patient has had a normal neurological examination including reflexes and a negative EMG for large fiber neuropathy. Thus, no red flags were present in the records. Per the National Imaging Associates (NIA) guidelines, the lumbar spine MRI was not medically necessary without a prior trial of conservative therapy. This patients records indicate the patient was referred for physical therapy but do not document that the patient was treated with physical therapy prior to the lumbar spine MRI. Thus, the lumbar spine MRI performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the diagnostic procedure 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 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 reimbursement for Carac 0.5% cream for treatment of the enrollees actinic keratosis. Findings: The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the medication at issue. This patient has been diagnosed with actinic keratosis, and she has tried and failed therapy with Picato. The Health Plan coverage criteria requires a treatment trial and failure of generic fluorouracil cream, generic fluorouracil solution or generic imiquimod cream prior to coverage of brand name Carac. These medications are useful for the treatment of pre-cancerous actinic keratosis, which has the potential to develop into squamous cell carcinoma if untreated. Thus, there were other effective, preferred formulary agents for the treatment of this patients condition. Therefore, Carac 0.5% cream was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the medication 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical total disc 2 level arthroplasty C6-C7 for treatment of the enrollees damaged cervical discs. Findings: Three physician reviewers found that Current evidence based medical peer reviewed literature supports 2 level cervical artificial disc replacement at two contiguous levels for intractable radiculopathy (arm pain and/or neurologic deficit) when specific criteria have been met. There is limited support for hybrid surgery (artificial disc replacement and anterior cervical discectomy and fusion) using the Bryan prosthesis for bi-level degenerative disc disease. However, a review of current medical literature did not reveal evidence based medical support for the addition of an artificial disc at the adjacent level to the Bryan prosthesis. This patient presents status post a C5-6 artificial disc replacement using the Bryan prosthesis. He has developed significant left C6-7 radiculopathy confirmed by imaging evidence of adjacent segment disease, and electrodiagnostic evidence of an acute C6-7 radiculopathy. He had apparently failed reasonable conservative treatment. The treating provider has opined the clinical necessity of adjacent level surgery. However, there is a lack of current peer reviewed support for the addition of a second cervical artificial disc replacement at the adjacent level next to a Bryan artificial disc replacement. There is limited support noted for a hybrid surgery combining the existing Bryan artificial disc with an anterior cervical discectomy and fusion. Therefore, cervical total disc 2 level arthroplasty at C6-7 is not likely to be more beneficial for the treatment of this patients medical condition than any available standard therapy.Final Result: The three physician 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. All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patches for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that the physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting opioids. Additionally, when opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to greater than or equal to 50 morphine milligram equivalents (MME) per day, and should avoid increasing dosage to greater than or equal to 90 MME per day or carefully justify a decision to titrate dosage to greater than or equal to 90 MME per day.  In this case, the patient has requested per day. No medical evidence-based rationale is given for this high of a dosage. Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. The records indicate that tolerance has taken place since the start of the narcotics. In this case, there is the possibility of opioid-induced hyperalgesia. No clear objective goals with this high of a dose of opioid have been established, and other non-pharmacological treatments have not been exhausted or even addressed. There is no documentation of behavior therapy despite significant research to support its use. All non-opioid medications classes have not been exhausted. The current medical evidence does not support the requested medication in this patients case. Therefore, fentanyl patches 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the ThyGenX testing for evaluation of the enrollees follicular lesion of undetermined significance.Findings: Three physician reviewers found that FNA is a well-established procedure in determining if a thyroid nodule is malignant or benign with good sensitivity for a papillary thyroid cancer. When FNA cytopathology comes back as indeterminate, repeat FNA and or thyroid surgery were the only options to get a definitive pathological diagnosis. The ThyGenX is a next generation sequencing panel designed to be used in patients with indeterminate thyroid FNA cytology results. Although the presence of certain mutations may predict more aggressive malignancies, the clinical utility of identifying these mutations preoperatively has not been established. Given the limitations in the evidence based literature, the use of molecular diagnostics in thyroid FNA samples for mutations associated with thyroid cancer is not the standard of care. In this case, cytopathology from FNA of the left thyroid cystic nodule was reported as benign, FNA cytopathology did not reveal indeterminate cytology. There is lack of clinical documentation provided to support molecular testing when cytology was not reported as indeterminate. All told, the ThyGenX testing 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 the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.