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 for 12 weeks for treatment of his Hepatitis C virus.  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. Delay in treatment may result in decreased survival. For these reasons, Epclusa is medically necessary for the treatment of the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested  reimbursement for the nerve stimulation treatment for his overactive bladder.Findings: Three physician reviewers found that the nerve stimulation treatment, procedure were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. The medical literature demonstrates significant improvement in overactive bladder symptoms using posterior tibial nerve stimulation (Burton, et al). In this case, the documentation submitted for review demonstrates that the patient tried on multimodal therapy without significant improvement in voiding symptoms. Given his lack of improvement with standard therapies, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for neuropsychological consultation for evaluation of the enrollee's behavioral health condition.Findings: The physician reviewer found that the request for a neuropsychological consultation is not medically necessary for evaluation of the patients medical condition. In this case, the patient has difficulty communicating effectively, with limited insight and self-reflection. For patients with low functioning ASD, behavioral therapy is recommended, which this patient is receiving along with in-home ABA. In general, neuropsychological consultations are utilized when there is a diagnostic issue. The record does not demonstrate that the patients diagnosis is at issue. The documentation submitted for review includes progress reports with scales and measurements that are typically performed during a neuropsychological consultation. The patients social skills, language, emotions, and attention are measured and monitored which is similar to what a neuropsychological assessment would entail. Therefore, a neuropsychological consultation is not medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested service is 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma gene expression classifier for evaluation of her indeterminate thyroid nodule. Findings:  All three physician reviewers found that while Fine Needle Aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of Fine Needle Aspiration biopsy results are considered indeterminate (Alexander, et al). Until recently, studies have shown that the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma Thyroid Fine Needle Aspiration Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on Fine Needle Aspiration biopsy, thereby decreasing unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. For the reasons stated above, the Afirma gene expression classifier provided was likely to have been more beneficial for the evaluation of this patient than any available standard therapy. Final Result: The reviewers determined that the services at issue were likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is 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 and prospective authorization and coverage for the medication Botox for treatment of her headache disorder.Findings: Three physician reviewers found that the documentation submitted for review fail to indicate several diagnostic criteria important in the classification of chronic migraine as well as any history of treatment of her headache disorder with associated success or failure.  As per the International Headache Society Classification for Headache Disorders, chronic migraine is defined as occurring greater than 15 days per month for greater than three months, headache not attributable to another disorder, at least two characteristics of unilateral, pulsatile, moderate to severe in intensity, or aggravation by or causing avoidance of routine physical activity. Additionally, there must be one characteristic of nausea and/or vomiting, photophobia and phonophobia. Botox is a tool in the management of chronic migraine which has shown effectiveness in the PREEMPT trials.  However, there were significant criticisms of their outcomes including absolute gain of headache free days, primary efficacy end point of PREEMPT 2, which was only 2.3 days on average over a 28 week period, high placebo effect, and the trials enrolled a majority of subjects with concomitant medication overuse headache possibly confounding the results.  In a study by Mathew and Jaffri, they compared Topamax, Botox, and placebo in a double blind study where the authors concluded OnabotulinumtoxinA and topiramate demonstrated similar efficacy in the prophylactic treatment of chronic migraine. In a study performed by Cady and colleagues, the study also failed to show statistical significance between group differences for efficacy variables, such as reduction in pain intensity and reduction in analgesic doses in Botox versus topiramate. The evidence available and the limitations in the PREEMPT trials suggest that Botox is no better than standard available therapy.  Additionally, there is insufficient documentation to support this patient has met criteria for chronic migraine. There is also a lack of documentation to support that this patient has attempted and failed other drug classes, which may be equally as effective. For these reasons, the medication Botox was not and is not likely to be more effective than the standard methods for the treatment of this patients medical condition.Final Result: Three reviewers determined that the medication 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: All three reviewers are board certified in neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 150 mg/mL syringes (every 2 weeks, length of therapy/number of refills: 11, quantity: 2 per 28 days) for treatment of the enrollee who has a history of hypercholesterolemia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Praluent (alirocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  The documentation provided does not support a history of heterozygous familial hypercholesterolemia. This diagnosis requires not only elevated LDL cholesterol levels that significantly exceed 180 mg/dL but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomatas), a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism, according to published criteria. Based on the documentation provided, a diagnosis of heterozygous familial hyperlipidemia cannot be made by usual accepted criteria. In addition, current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. For these reasons, Praluent 150 mg/mL syringes (every 2 weeks, length of therapy/number of refills: 11, quantity: 2 per 28 days). 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: An enrollee has requested authorization and coverage for Repatha Sureclick 140 ng/mL for treatment of the enrollees hyperlipidemia and coronary artery disease status post myocardial infarction. Findings:  The physician reviewer found that Repatha has been approved by the U.S. Food and Drug Administration (FDA) for patients with clinical atherosclerotic cardiovascular disease who have not achieved goal LDL levels despite maximal tolerate statin doses. In 2013, the American College of Cardiology (ACC) established recommendations for treatment groups and high intensity statin moving away from specific LDL target numbers. Overall, the guidelines suggest that the evidence for benefit of treating to a certain target LDL was lacking. Colleagues reported on the FOURIER trial with outcome benefits. However, the absolute reduction was about 2% reduction in composite endpoints and this trial was not included in the ACC guidelines. This patient has reached an LDL of 88 mg/dL on high intensity statin and there is a lack of data supporting the benefits of achieving a specific target level less than 70 mg/dL as recommended by the patients provider. For these reasons, the requested Repatha Sureclick 140 ng/mL 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient behavioral health level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that this patient presents with a serious, chronic mental illness that has required specialized medical care including treatment with clozapine, an antipsychotic medication typically reserved for patients with refractory psychotic illnesses. The records indicate that the acute episode of illness that prompted the admission has improved as the patient is eating well, sleeping restfully and taking his medication. However, the patient continues to require inpatient behavioral health level of care services. Due to the considerable impairment, past history and poor prognosis, a premature or inappropriate discharge would only serve to increase the patients chances of a prompt re-admission, while exposing the population to potential risk of harm. The patient requires a locked and supervised setting with trained medical professionals, including access to psychiatric specialty care. While the inpatient treatment team works to place the patient in a residential facility for long-term treatment of his behavioral condition, continued inpatient services are appropriate. Thus, the inpatient behavioral health level of care services provided were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are 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 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 neutron beam radiation therapy for treatment of the enrollees recurrent adenoid cystic carcinoma in the mediastinum. Findings:  The physician reviewer found that there is a paucity of medical literature to support treatment with neutron radiation therapy for recurrent cancer. As noted by the National Comprehensive Cancer Network (NCCN), the data does not demonstrate that neutron radiation offers a clinical benefit compared to conventional radiation therapy techniques for adenoid cystic carcinoma. Further, neutron therapy is known to increase late complication rates compared to standard treatment with photon therapy. There are multiple studies which demonstrate that photon therapy can be safely administered to the mediastinum with acceptable risks of local control and toxicities. Based on these reasons, the requested neutron radiation therapy is not medically necessary for treatment of this patients adenoid cystic carcinoma of the lung. 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 radiation oncology 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 venous angioplasty provided for her diagnosis of Paget-Schroetter syndrome.  Findings: Three physician reviewers found that the documentation as well as the literature support the procedure at issue in this clinical setting. The patient was treated for subclavian vein thrombosis with thrombolysis. On follow-up, there was some residual thrombus that was removed and intravascular ultrasound confirmed a tight narrowing in the subclavian vein. The venous angioplasty performed was indicated to prevent recurrent DVT. Therefore, the venous angioplasty performed  was likely to have been more effective than other methods for treatment of this patients medical condition.Final Result: Three reviewers determined that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The three reviewers are board certified in vascular surgery 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 parent of a two-year-old male enrollee has requested authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees behavioral issues. Findings:  The physician reviewer found that early intervention services are medically necessary for children diagnosed with autism spectrum disorder. Colleagues studied children enrolled in a multidisciplinary team approach, similar to the proposed IOP program in this case. The authors reported that the children demonstrated significant gains in overall functioning that was sustained on follow evaluations two years later. Occupational therapy has also shown to be beneficial in the treatment of autism, addressing postural control and adaptive skills for long-term independence. In addition, the use of cognitive behavioral therapy has been shown to be beneficial in the treatment of children with autism, successfully addressing common problems such as feeding difficulties. Given the support in the peer-reviewed literature demonstrating the benefit of early intervention in children with autism, coupled with the patients resistance to transitions and rigidity, outburst behaviors and tantrums, the request for IOP services is medical necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 developmental-behavioral pediatrics 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 Praluent 75 mg /mL for treatment of the enrollee who has a history dyslipidemia. Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity for the requested medication. In this case, the records do not indicate that this patient has completed an adequate trial with Zetia in addition to maximally tolerated statins. The provider noted that Zetia would not be effective in lowering the patient to her LDL goals. However, the providers statement was not supported by the submitted clinical records or current peer-reviewed medical literature. Specifically, there was no documentation regarding a trial or failure of Zetia for this patient. As such, Praluent 75 mg/mL is not 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 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.