Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the Rezum procedure. The Rezum is a novel technique to treat male urinary symptoms secondary to BPH due to an enlarged prostate. However, the American Urological Association (AUA) guidelines state that, water vapor thermal therapy may be offered to patients with lower urinary tract symptoms attributed to BPH provided prostate volume less than 80 g; however, patients should be informed that evidence of efficacy, including longer-term retreatment rates, remains limited. Given the lack of studies and clinical guidelines reporting improved health outcomes at long-term follow-up, the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested Rezum procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara 45 mg/0.5 mL subcutaneous solution prefilled syringe. The patient has tried and failed other therapies. The patients provider reports that due to her childbearing potential, the use of methotrexate, acitretin and biologics are contraindicated. However, the provider is requesting Stelara, which is a biologic. In addition, Stelara is not preferred in pregnancy category over the preferred agents. As there is no true contraindication or reason provided as why the preferred agents cannot be used in the patient for treatment of chronic plaque psoriasis, the requested Stelara 45 mg/0.5 mL subcutaneous solution prefilled syringe is not supported as 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 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: A patient has requested authorization and coverage for Subsys 100 mcg spray. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients postdural puncture headache. The submitted documentation does not support the medical necessity of the requested medication. According medical guidelines, chronic use of opiates for non-malignant pain is not recommended. Further, risk evaluation and mitigation strategy dispensing guidelines state that Subsys is restricted to cancer related pain. Therefore, Subsys 100 mcg spray is not medically reasonable or necessary for 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A patient has requested authorization and coverage for methadone. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the patients pain at this time. The Health Plan advised that the patient taper off the requested medication to a safe dose and talk to their doctor about other medications. The submitted documentation does not support the medical necessity of the requested medication regimen. This patient is being tapered off methadone in accordance with Centers for Disease Control and Prevention (CDC) clinical practice guidelines. A randomized clinical trial conducted revealed that there are several non-opioid medications and physical medicine therapies that can be used to treat patient with multiple types of pain, including chronic back pain. Therefore, methadone is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 Mavyret 100-40 mg, three tablets by mouth daily for eight weeks. 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 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg, three tablets by mouth daily for eight weeks are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocortisone acetate 25 mg suppositories. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The American College of Gastroenterology guidelines for management of benign anorectal disorders do not recommend hydrocortisone acetate 25 mg suppositories over the formulary alternatives. The formulary alternative, hydrocortisone cream 1%, is effective based on current medical literature. There is a lack of high-quality controlled trials showing that hydrocortisone acetate 25 mg suppositories are superior to the formulary alternative, and there are no reported contraindications to the formulary alternative. Therefore, hydrocortisone acetate 25 mg suppositories 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 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: A 32-year-old female enrollee has requested authorization and coverage for Boosted Exome Proband Test, Ehlers Danlos syndrome panel testing (15 gene test), and Nutri-Spec testing services for treatment of the enrollee's medical condition.  Findings:  The physician reviewer found that The requested Boosted Exome Proband Test is not medically necessary for evaluation of this patient. This patient has a number of diagnoses, but none have been associated with specific genetic defects. The patients other diagnoses, including fibromyalgia, SIBO, endometriosis, and IBS, are not known to be caused by single gene defects. Additionally, these are not likely to be due to a single, unifying diagnosis of a Mendelian disorder. Accordingly, the requested Boosted Exome Proband Test is not medically necessary. In addition, testing of genes associated with Ehlers-Danlos syndromes is not medical necessary for this patient and is not necessary to make a diagnosis of hypermobile Ehlers-Danlos syndrome. Hypermobile Ehlers-Danlos syndrome is diagnosed or ruled out clinically. The genes included in Ehlers-Danlos syndromes panel testing are for the other causes of Ehlers-Danlos syndromes, each of which has specific identifiable clinical features, and none of which have been described in this patient. Therefore, any concern for hypermobile Ehlers-Danlos syndrome should be evaluated by the patients provider without need for genetic testing. Thus, the requested Ehlers-Danlos syndromes panel testing (15 gene test), is not supported as medically necessary for evaluation of this patients medical condition. Finally, Nutri-Spec testing is not supported as medically necessary for evaluation of this patients medical condition. The Nutri-Spec testing is not Clinical Laboratory Improvement Amendment (CLIA) certified. Further, the U.S. Food and Drug Administration (FDA) issued a warning about the company marketing this testing in December 2014. Given the lack of support or clinical indication for this testing, the requested Nutri-Spec testing is not medically necessary. All told, the requested Boosted Exome Proband Test, Ehlers-Danlos syndromes panel testing (15 gene test), and Nutri-Spec testing services are not medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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 genetics and clinical biochemical genetics 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: A 32-year-old female enrollee has requested authorization and coverage for S-Boulardii, Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, L-Arginine low dosage, D-Ribose pure powder 500 mg, and Natural Calm plus calcium supplements for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that The request for Saccharomyces boulardii (S-boulardii) is supported as medically necessary for treatment of this patients medical condition. This probiotic has demonstrated efficacy for the treatment of irritable bowel syndrome, which this patient has (Kelesidis and Pothoulakis,). However, the remaining requested items are not supported as medically necessary. Data to support the use of L-arginine supplementation for medical diseases is sparse, and possible benefits published in current medical literature may include hypertension and reduction hospital-acquired infection, although the data are limited; these are not the requested indications in this case (McRae). Overall, there is a lack of peer-reviewed published medical literature citing clinical trial data to support the use of Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, D-Ribose pure powder 500 mg, and Natural Calm for any medical indication. The American College of Gastroenterology (ACG) guidelines for the management of IBS do not support these therapies for treatment of patients with IBS (Ford, et al). For these reasons, the request for S-boulardii is supported as medically necessary in this case, but the Lifeway Kefir (lactose free), pyrroloquinoline quinone 20 mg, L-Arginine low dosage, D-Ribose pure powder 500 mg, and Natural Calm plus calcium supplements are not supported as medically necessary. Final Result: The reviewer determined that a portion of the requested products are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Dexcom 6 continuous glucose monitoring system. The submitted documentation supports the medical necessity of the requested device. A continuous glucose monitoring system is a U.S. Food and Drug Administration (FDA) approved device that records blood sugar levels at repeated intervals throughout the day and night. The main advantage of continuous glucose monitoring is that it can help identify fluctuations and trends that would otherwise go unnoticed. The device can help maintain tight glycemic control and prevent hyperglycemia and hypoglycemia. It can capture dangerously low overnight blood sugar levels which often go undetected, reveal high blood sugar levels between meals, show early morning spikes in blood sugar, and evaluate how diet and exercise affect blood sugars. It can be used as a precautionary device in order to prevent potentially dangerous consequences of uncontrolled diabetes.  Continuous glucose monitoring system have been shown to improve hemoglobin A1c levels of diabetic patients. This patient has been unable to optimize his glycemic control and is at risk of dangerous consequences due to his hypoglycemic unawareness. Therefore, the requested Dexcom 6 continuous glucose monitoring system is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested device is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sensipar. The records provided for review document the patient has a hyperplastic parathyroid gland that has not reduced in mass since his kidney transplant. The parathyroid gland is hyperactive and cannot be inhibited with non-calcium binders. Oral vitamin D is also contraindicated as it would worsen the patients hypercalcemia. Treatment options are limited to surgery or Sensipar to avoid the risk of nephrolithiasis. Thus, Sensipar is appropriate as the least invasive and most effective treatment option. Accordingly, the requested Sensipar is supported as medically necessary for treatment of this patients medical condition. 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 nephrology 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 home birth with water birth. There is a lack of support for the requested services in this clinical setting. The American College of Obstetricians and Gynecologists (ACOG) noted that women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although planned home birth is associated with fewer maternal interventions than planned hospital birth, it also is associated with a more than twofold increased risk of perinatal death (12 in 1,000) and a threefold increased risk of neonatal seizures or serious neurologic dysfunction (0.40.6 in 1,000). ACOG reported that there is a lack of adequate randomized clinical trials of planned home birth. The medical evidence has not shown that a home water birth is as safe as delivery within a hospital environment. Therefore, the requested home birth with water birth 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left knee and lower leg. The submitted documentation supports the medical necessity of the requested services. There is significant evidence documenting severe osteoarthritis of the left knee. The patient experienced onset of severe pain and a lump in the popliteal area with radiation of pain down the calf and difficulty walking. The patient was evaluated by a primary care provider who recommended further evaluation with MRI. This patients popliteal pain, radiating severe calf pain resulting in difficulty walking is consistent with a leaking ruptured Bakers cyst. According to researchers, the current medical literature supports MRI as the imaging of choice for the evaluation of a possible Bakers cyst. As such, the requested MRI of the left knee and lower leg is medically necessary for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for anastrozole. The submitted documentation fails to demonstrate the medical necessity of the requested medication. The use of anastrozole is not a widely accepted method to increase height potential of short children. There are safety concerns that have not been adequately addressed. This patient is not the typical short child where studies with anastrozole have been shown to have some benefit. Per the records, it is likely that his short stature is a result of the other medical problems he has had, including nutritional issues and a history of small for gestational age. The use of anastrozole in the setting of nutritional defect has not been proven in clinical studies. This patient has an estimated predicted height of 56 with the current therapy, which is a normal adult height. Anastrozole is an aromatase inhibitor that blocks the conversion of testosterone to estradiol and can delay bone age advancement caused by increasing levels of testosterone in otherwise healthy short boys that progress in puberty physiologically. However, this patient does not have the typical problem of otherwise healthy short boys because he has partial testicular failure and is on treatment with testosterone. Thus, anastrozole is 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 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.