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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for skilled nursing facility services. Findings:  The physician reviewer found that The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the services at issue. This patient sustained a distal left clavicular fracture, treated non-operatively, and a right distal ulnar shaft fracture. She required non-weight-bearing restrictions and sling use on each side. Per the records, there were no lower body injuries or impairments.  She was otherwise able to transfer and ambulate. Her needs were custodial in nature and could have been met in the community with 24 hour per day caregiver assistance/supervision and home-based therapy services to include early range of motion and gradual institution of strengthening. The records do not demonstrate the medical necessity for inpatient-based skilled therapy services or skilled nursing needs. The medical evidence does not support the services at issue in this clinical setting. All told, skilled nursing facility services provided  were not medically necessary for the treatment of this patient. 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 physical medicine and rehabilitation 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 breast reduction surgery. The Health Plan has denied this request indicating that the requested for treatment of the enrollees bilateral symptomatic macromastia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The records document evidence of symptomatic macromastia. She has neck, back and shoulder pain directly attributed to her documented macromastia. Per the American Society of Plastic Surgeons (ASPS), coverage for symptomatic breast hypertrophy should be based upon documentation of at least two symptoms regardless of body weight or weight of breast tissue removed. These symptoms include chronic breast pain due to weight of the breasts, intertrigo unresponsive to medical management, upper back, neck, and shoulder pain, unspecified backache, acquired thoracic kyphosis, shoulder grooving from bra straps, upper extremity paresthesia due to brachial plexus compression syndrome secondary to the weight of the breasts being transferred to the shoulder strap area, headache and congenital breast deformity. Based on the documentation provided, this patient does not satisfy the above criteria as supported by the ASPS, as she should have two of the above signs or symptoms, but has only been documented to have upper back, neck and shoulder pain, which is classified as one symptom. 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 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 the enrollee has requested authorization and coverage for human growth hormone (GH) therapy with Nutropin AQ for treatment of the enrollees small for gestational age (SGA), poor weight gain, and short stature. Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) has approved an indication for the use of GH therapy in patients with SGA. It is estimated that 9 out of 10 children born SGA experience rapid catch-up growth during the first 12 months of life, but 10-15% do not experience catch-up growth. The data in the medical literature indicate that GH treatment in short children born SGA is intended to achieve more normal height in early childhood, then maintain a normal height gain and reach adult height within the normal target genetic range. The records indicate that this patient was born early and at six years, his weight is consistent with a four-year-old, and a height age of 3.5 years. Given the bone age of seven years at a chronological age of five years eight months projects a very low adult predicted height of five feet two inches. This is well below the genetic target of six feet one inches. Of note, the bone age is typically delayed compared to chronological age in short prepubertal children born with SGA. The laboratory studies obtained so far in this patient indicate normal insulin like growth factor-1 (IGF-1) and normal insulin like growth factor binding protein-3 (IGFBP3). Provocative GH stimulating testing has not reportedly been done. GH deficiency appears extremely unlikely in this setting given these data. Given this patients presentation, treatment with human GH therapy with Nutropin AQ is supported as medically necessary. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Mavyret 100-40 mg tablet for eight (8) 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 support treatment with Mavyret for non-cirrhotic treatment naive genotype 1 patients 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 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablet for eight (8) 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Praluent for treatment of the enrollees familial hyperlipidemia, coronary artery disease, and ischemic chest pain. Findings:  The physician reviewer found that based on the records provided, the patient presents with hyperlipidemia and intermittent chest discomfort but no provokable ischemia on stress testing and no obstructive coronary disease on angiography. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease as evidenced by myocardial infarction, coronary bypass, provokable ischemia on stress testing, stroke, or transient ischemic attack who require additional lowering of LDL cholesterol. This patient does not meet these criteria. Familial hyperlipidemias require elevated LDL cholesterol levels that significantly exceed 180 mg/dL as well as a combination of physical examination findings such as arcus cornealis below the age of 45 or tendon xanthomatas, a strong family history of coronary disease with diagnosis in a relative younger than 50 years in a second-degree relative or younger than 55 years in first-degree relatives, and documented genetic defects related to cholesterol metabolism according to published criteria. PCSK9 inhibitors have not been studied in other patient populations. Moreover, current guidelines endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this clinical setting.  Finally, this patients LDL is close to goal on statin medication and the addition of Zetia in this setting has been shown to result in incremental reduction in LDL cholesterol levels with improvement in outcomes.  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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for special portable ramps to be used in the bathroom for treatment of the enrollees stroke with left-sided hemiparesis. Findings:  The physician reviewer found that the request for special portable ramps to be used in the bathroom is not medically necessary for treatment of this patients medical condition. DME is defined as equipment that is used to treat or manage a disease, injury, or disability. This patients documentation does not reveal that a portable ramp will alter this patients disease, injury or disability. The therapy documentation reveals that patient has made significant progress and the caregivers are already independent in assisting the patient to transfer to the shower with use of a Hoyer lift and a new shower chair. A DME evaluation by a therapist deemed that an additional ramp would be a convenience item. The documentation does not reveal that a ramp is needed to enter the bathroom and the patient is currently able to transfer to the shower with caregiver support. The patients current method of entering the shower is described as safe. The provider that evaluated the home noted that the ramp was a convenience item rather than medically necessary. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: An enrollee has requested authorization and coverage for Otezla 30 mg tablets for treatment of the enrollees arthropathic psoriasis. Findings:  The physician reviewer found that the request for Otezla 30 mg tablets is not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to demonstrate that the patient has had a trial and failure of methotrexate and tumor necrosis factor (TNF) inhibitors such as Enbrel and Humira. Based on the clinical records submitted for review, the request for Otezla 30 mg tablets has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 Guardant360 biopsy free tumor sequencing test for evaluation of the enrollees non-small cell lung cancer metastatic to the brain. Findings:  The physician reviewer found that to demonstrate the clinical utility of Guardant360 in this setting, prospective, randomized clinical trials are needed to compare the strategy of targeted treatment based on panel results with the standard of care. The available literature on its clinical utility consists of a small number of uncontrolled studies and nonrandomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions as to its clinical utility. In the event a tissue biopsy cannot be obtained or is unsafe to conduct a plasma biopsy, using panel tests such as Guardant360 maybe useful to look for the actionable mutations. In this case, this patient had undergone tissue testing of the lung biopsy and metastatic brain tissue was tested for the recommended genomic tests. Guardant360 testing remains investigational in metastatic lung cancer and should only be used as part of a clinical trial when a tissue specimen is available and has been tested for genomic abnormalities. In addition, there is potential for harm if ineffective therapy is given based on test results, because there may be adverse effects of therapy in absence of a benefit. 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Otezla is a U.S. Food and Drug Administration approved treatment for psoriasis and psoriatic arthritis. In this case, the patient has chronic plaque psoriasis and has failed therapy with topical steroids and Enbrel. However, the Health Plans recommendation for treatment failure of two formulary alternatives that include Humira and Cosentyx is medically reasonable and appropriate. Given the lack of treatment failure, contraindication or intolerance to at least two of the preferred medications, the request for Otezla has not been established as medically necessary for treatment of the patients chronic plaque psoriasis. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for a wearable cardioverter defibrillator rental for treatment of the enrollees cardiomyopathy. Findings:  Three physician reviewers found that based on the records provided the patient presents with a newly recognized cardiomyopathy in the setting of rapid atrial fibrillation. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction  35%) is documented to persist in spite of appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. Moreover, more recent retrospective trials in patients with newly diagnosed non-ischemic cardiomyopathy have not demonstrated benefit with prophylactic wearable defibrillators. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (or required explantation. As such, the use of a wearable defibrillator in this circumstance is not supported in the scientific literature. Final Result: The reviewers determined that the device at issue was not and 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Oncotype DX testing for evaluation of the enrollees prostate cancer. Findings:  Two physician reviewers found that once prostate cancer is diagnosed in a pathologic specimen, risk stratification is performed by the analysis of certain features such as the grade of tumor and PSA level. This helps guide the most appropriate therapy for patients taking into account their age and co-morbidities because many patients will not require therapy and may be followed closely instead. The important features to recognize are Gleason score and PSA but these are imperfect. Thus, current biomarkers are inadequate for risk stratification and better prognostic biomarkers are needed. The Oncotype DX test is a gene expression analysis of target genes in the biopsy specimen that generates a genomic prostate score (GPS). A validation study was presented at the American Urological Association meeting in 2013 involving 395 patients. The GPS identified patients that had very low risk disease that could be followed rather than referred for surgery. Given that the current prognostic features are inadequate to make firm recommendations regarding active surveillance to patients, the Oncotype DX testing performed was medically appropriate and 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 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: 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.