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 Epclusa 400-100 mg tablets for 12 weeks. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 6 patients should be treated with Epclusa for 12 weeks, based on a 100% cure rate in the ASTRAL-1 trial. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg tablets 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 gene testing. Three physician reviewers the National Comprehensive Cancer Network guidelines indicate that while there is interest in newer prognostic molecular techniques, such as gene expression profiling, routine prognostic genetic testing of primary cutaneous melanoma before or after sentinel node biopsy is not recommended outside of a clinical trial. At this time, there is a lack of studies comparing outcomes of standard of care with outcomes determined by using the test. Therefore, gene testing was not likely to have been superior over other methods of evaluating this patient. Final Result: The 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: Physician 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: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks.Findings: 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 and Zepatier with ribavirin for 16 weeks when NS5A resistance is present. However, the guidelines now state that lack of NS5A resistance testing in genotype 1a patients should not be an impediment to coverage, and recommend 12 weeks of Zepatier when NS5A resistance testing is not available. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier 50-100 mg tablets daily for 12 weeks is medically necessary for this patient.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for a real time remote heart monitor. Findings:  Two of the three physician reviewers found that in this patients case, the records note a reported transient ischemic attack of uncertain cause with a suspicion of possible transient atrial fibrillation. In this circumstance, evaluation for transient atrial fibrillation should be sufficiently performed using a combination of serial Holter monitoring and data obtained from an implantable loop recorder, both of which already have been provided to the patient. Real-time remote cardiac telemetry is not indicated since the patient already has implantation of an implantable loop recorder that should be able to sufficiently detect transient atrial fibrillation. Therefore, the requested real time remote heart monitor is not likely to be superior over other methods of evaluating this patient. Final Result: The reviewers determined that the requested device is 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: Physician reviewers 1, 2 and 3 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 reimbursement for DecisionDx-Melanoma Assay. Findings:  Three physician reviewers found there is a lack of support for the services at issue in this clinical setting. This patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques, such as gene expression profiling, to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Therefore, DecisionDx-Melanoma Assay was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for DecisionDx-Melanoma Gene Assay. Findings:  Three physician reviewers found this patient has an early stage melanoma. The National Comprehensive Cancer Network guidelines indicate while there is interest in newer prognostic molecular techniques such as gene expression profiling to differentiate melanomas at low versus high risk for metastasis, routine prognostic genetic testing of primary cutaneous melanomas is not recommended outside of a clinical study. Thus, the medical evidence does not support the services at issue in this clinical setting. Therefore, DecisionDx-Melanoma Gene Assay was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: The 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: Physician 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: An enrollee has requested authorization and coverage for Cialis 5 mg, daily. Findings: The submitted documentation supports the medical necessity of the requested medication quantity. Cialis tadalafil 5 mg once daily is an option for the treatment of men with erectile dysfunction. In two recent studies, treatment with tadalafil once daily improved erectile function in men with mild-moderate impairments in erectile function following failed as needed or on demand phosphodiesterase type 5 inhibitor treatment. This patient has failed to respond to prior medications, and he reported benefit with daily Cialis. As such, use of Cialis 5 mg daily is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for laboratory testing. Findings:  Three physician reviewers found that FibroTest has been demonstrated to reliably determine the presence of advanced fibrosis and cirrhosis in a variety of liver diseases, including hepatitis C. Patients with cirrhosis due to hepatitis C or other causes require management of cirrhosis to avert complications.  Liver biopsy, unlike FibroTest, is invasive, with risks including bleeding and bile duct injury. It is subject to interoperator variability during interpretation, and it is also subject to sampling error. The current medical evidence supports the laboratory testing performed in this patients case. Thus, laboratory testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove an ovarian cyst. The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient appears to have a longstanding asymptomatic dermoid cyst. In order to confirm this, the patient needs to have imaging. Ultrasound is the preferred initial assessment of the cyst. The cyst may be further characterized by magnetic resonance imaging (MRI). Surgical intervention for an asymptomatic, stable ovarian cyst is not indicated. Therefore, the requested surgery to remove an ovarian cyst is not medically necessary for the treatment of this patient.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 obstetrics and gynecology 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 Genotropin MiniQuick 1.2 mg SQ injection daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees idiopathic short stature.Findings: The medical necessity for growth hormone therapy is not supported by the submitted records. Based on the documentation provided, the patient may have a component of short stature, on the basis of mild constitutional delay. The patients adult predicted height is at the lower limit of normal for the presumed genetic target. As such, the data provided does not indicate that the patient meets criteria for supplemental growth hormone therapy. The ongoing height velocity appears to be consistent with what is commonly observed in children with short stature on the basis of constitutional delay. The available laboratory data does not support a diagnosis of growth hormone deficiency. Accordingly, growth hormone therapy would not be recommended based on this patients current growth pattern. Therefore, Genotropin MiniQuick 1.2 mg SQ injection daily has not been established as medically necessary for the 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flector patches. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic pain and muscle spasms.The medical literature does not support the use of Flector patches for muscle spasms in the chronic pain setting or for coccydynia. In the documentation available for review, the patient has multiple pain areas although the most significant are the hip and tailbone regions. Thus, topical Diclofenac 1% could be used. Moreover, an administration notes that gastrointestinal bleeding is a possibility with Flector patches. Acetaminophen is a preferred choice for pain relief in the bariatric patient but the records indicate that the patient is not taking them consistently. Furthermore, it is recommended that if NSAIDs are used, a proton pump inhibitor should be taken in the post bariatric surgical patient. In sum, the medically necessity for Flector patches has not been demonstrated for the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bilateral mastectomy. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees gender dysphoria and are not reconstructive in nature. Findings: There is support in the medical literature for the services at issue in this clinical setting. This patient has documented gender dysphoria and is in transition to becoming a male. The Health Plan denied bilateral mastectomy based on the patients current weight of 217 pounds. The record noted that the patient has attempted weight loss beginning in June 2016 with some success initially. Based on the documentation provided, he has evidence of abnormal breasts for the male gender despite the use of hormonal therapy. This condition would not likely resolve with continued hormonal therapy. Given the overall presentation of this patient, his body mass index (BMI) should not be an absolute contraindication to bilateral mastectomy. The research shows inconclusive evidence that the overall postoperative complications of reduction mammaplasty increases as BMI increases. Patients undergoing reduction mammaplasty with high BMI (>25) experience the same complications and at similar rates as patients with normal BMI ( 25). The patient has attempted to lose weight and has had some success. Patients of all BMI ranges experience similar benefits from reduction mammaplasty. Thus, it has not been established that the patient would experience an increased complication rate due to his increased BMI if the reduction or mastectomy is performed.  Therefore, bilateral breast mastectomy is medically necessary for treatment of this patients gender dysphoria.With regard to whether the requested services are reconstructive in nature, the submitted documentation as well as the photographs reveal that the patients breast development constitutes an abnormal structure for a male who has failed hormonal therapy. The patients breast development constitutes an abnormal structure of the body. The appearance of the patients breasts should be more consistent with an adult male. The abnormal structure of the body is caused by a developmental abnormality, specifically, the patients gender dysphoria. The plan of the surgery is to create a more normal appearance for a male and to create a relatively normal appearing male chest.  Additionally, the surgery would offer more than a minimal improvement in the appearance to the best extent possible. In summary, bilateral breast mastectomy is reconstructive in nature. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Based upon the evidence submitted for review, the patient was assessed psychiatrically and medically during his admission. The patient was deemed to have no safety risk. During the assessment and throughout the patient's residential treatment, the patient did not receive treatment for a psychiatric emergency medical condition. The patient was not assessed as, nor did he suffer from, a psychiatric emergency medical condition. He was not self harming, suicidal or homicidal and therefore not a danger to himself or others. He was cognitively intact, and showed no immediate risk of withdrawal as he had just completed a two week detoxification program. Given this, his symptoms would be considered post-acute withdrawal symptoms. Management of the patients medications could have been provided on an outpatient basis. All told, the patient was not experiencing a psychiatric emergency medical condition during the period at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services during the period at issue. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for D cup breast implants as part of mastopexy. Findings:  The physician reviewer found that This patient has lost a significant amount of weight following bariatric surgery.  She is noted to have significant rashes associated with her ptotic breasts from skin-to-skin contact. A mastopexy is indicated for functional improvement, and this procedure was approved by the Health Plan. However, per the submitted documentation, breast augmentation for this patient is a cosmetic intervention and is not medically necessary.  The records document that the patient has ptotic breasts of moderate size, which is confirmed by the photographs.  Other than the ptosis of the breasts, the patient has a normal breast appearance for her current body size and weight. The ptotic aspect of the breasts will be addressed with the mastopexy, which has been approved. Thus, as the patient has a normal appearance with respect to breast volume, the requested services with not be performed to create a normal appearance. Additionally, the records do not document that the requested services will improve function. Therefore, the requested D cup breast implants as part of mastopexy are not medically necessary for the treatment of this patient and are not reconstructive in nature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition and are not reconstructive in nature. 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.