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 Humira pen (adalimumab pen injector kit 40 mg/0.8 ml). Findings:  The physician reviewer found that there is sufficient support in the medical literature for the requested medication in this clinical setting. The 2015 European League Against Rheumatism (EULAR) guidelines for the treatment of psoriatic arthritis (PsA) state that with regards to PsA, The first biologic disease-modifying antirheumatic drug (bDMARD) would usually be a tumour necrosis factor (TNF) inhibitor; bDMARDs targeting interleukin (IL)12/23 (ustekinumab) or IL-17 pathways (secukinumab) may be used in patients for whom TNF inhibitors are inappropriate and a tsDMARD such as a phosphodiesterase 4-inhibitor (apremilast) if bDMARDs are inappropriate. If the first bDMARD strategy fails, any other bDMARD or tsDMARD may be used. In this case, the patient has a history of psoriasis, PsA and arthritis mutilans. The international guidelines for the treatment of PsA recommend TNF inhibitor as first line therapy.  However, step therapy would not be warranted at this time because PUVA and UVB only treat psoriasis and not PsA. The records also note that the patient is intolerant to any form of methotrexate but she has responded very well to Humira. With regards to the patients psoriasis and psoriatic arthritis, acitretin would treat only skin disease and not the arthritis. As for the medication cyclosporine, the patient has a history of hypertension, which can be significantly worsened by this medication.  This patient has been on Humira for several years and appears to be doing well. As such, Humira pen (adalimumab pen injector kit 40 mg/0.8 ml) is medically necessary for the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier test for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that while a 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 to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, the Afirma Gene Expression Classifier test, helps determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for 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. Therefore, the Afirma Gene Expression Classifier test was likely to have been more effective 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for bilateral automated whole breast ultrasound for evaluation of the enrollees dense breast tissue. Findings:  Two physician reviewers found that in the peer-reviewed medical literature, researchers compared the performance and diagnostic yield of mammography alone versus an automated whole breast ultrasound (AWBU) plus mammography in women with dense breasts and/or at elevated risk of breast cancer. The authors found that a blinded study of this system combined with screening mammography showed that adding AWBU both doubles overall cancer detection and triples the 1 cm-or-less invasive cancers found in dense-breasted women. Thus, the literature does support the use of adding AWBU to mammography for improved breast cancer detection for dense breasted women. Accordingly, the requested bilateral automated whole breast ultrasound is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested diagnostic procedure is 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 diagnostic radiology 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 for 12 weeks. Findings:  The physician reviewer found that according to the 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 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infectionFinal 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 authorization and coverage for an insulin pump for treatment of the enrollees uncontrolled type 2 diabetes. Findings:  Two physician reviewers found that the requested device is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Insulin pump therapy and multiple dose insulin (MDI) regimen use in patients with type 2 diabetes has not shown significant difference in glycemic control. A study evaluated the safety of a hybrid closed-loop system in patients with type 1 diabetes. The authors concluded that, Longer-term registry data and randomized studies are needed to further characterize the safety and efficacy of the hybrid closed-loop system. At this time, the incremental benefit of automated closed-loop control of insulin administration is unclear. There is a lack of long-term data available demonstrating health outcome benefits of such technology compared to other treatment methods, including multiple daily injection therapy and continuous insulin infusion therapy with or without a threshold suspend device. The requested MiniMed system is not clinically indicated given the lack of long term studies of this system and lack of data to show it is beneficial for treatment of patients with type 2 diabetes. For the reasons provided, the requested insulin pump 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 device 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 endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for mifepristone (Korlym) 300 mg tablet. Findings:  The physician reviewer found that Korlym is U.S. Food and Drug Administration (FDA) approved for use in patients with Cushings syndrome who are not candidates for surgery. However, this patients records do not meet the criteria for a diagnosis of Cushings. In addition, there is a lack of documentation demonstrating that the patient has excessive cortisol levels or pseudo-Cushings syndrome. Hence, the requested mifepristone (Korlym) 300 mg tablet 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 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 general anesthesia services during a dental procedure, wisdom teeth extraction, and teeth cleaning. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  General anesthesia for adults with developmental delay is generally considered to be a safe and effective practice. Behavioral management of mentally challenged patients can be problematic whether in a dental office or in an operating room. There is difficulty due to the patients inability to cooperate. The records also note that there is the possibility of aggressive or even combative behavior.  Often, this kind of developmental delay makes it difficult to obtain a complete preoperative medical assessment. Studies have shown that adults with developmental disabilities can be safely managed under general anesthesia for dental treatment in an operating room/hospital setting with minimal morbidity and without extensive preoperative investigations. The documentation provided notes that this patient has significant cognitive impairment and is unable to cooperate and tolerate dental treatment in an office setting. The patient has met the criteria as outlined in the medical record. The use of in office conscious sedation is not feasible based on the medical needs of this patient. 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 anesthesiology 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 of Zepatier 50-100 mg tablets for 12 weeks. Findings:  The physician reviewer found that according to the 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 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with  Zepatier 50-100 mg for 12 week to treat hepatitis C 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 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: The patient has requested reimbursement and prospective authorization and coverage for intensive outpatient program (IOP) services for treatment of the enrollees schizophrenia.  Findings:  The physician reviewer found that based on the available documentation, the services provided could not have reasonably been delivered effectively in a less restrictive setting. The records document that this patient has a prominent formal thought disorder. He is being treated with two potent antipsychotics, lurasidone and clozapine, as well as a mood stabilizer, divalproex. Although the psychiatry notes from report some progress, the patient continues to demonstrate disorganized thinking, episodic irritability and emotional reactivity leading to self-defeating behaviors. In sum, the patient has not consolidated the treatment gains necessary to succeed in a less restrictive setting. The setting and services, which include evidence based interventions such as dialectical behavioral therapy (DBT), assertive community treatment, mindfulness, cognitive rehabilitation, art therapy, psychoeducation, individual therapy and pharmacotherapy, remain appropriate and consistent with good medical practice. Moreover, these services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the IOP services were and are medically necessary for treatment of the patients behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Linzess for treatment of the enrollees constipation. Findings:  The physician reviewer found that the American Gastroenterological Association (AGA) and American College of Gastroenterology state that if an osmotic agent such as Miralax and then another type of laxative fail, a newer agent such as Linzess or Amitiza should be considered. The patient has responded well to Linzess and there is no bowel obstruction reported in this case. For these reasons, Linzess is supported as medically necessary for the treatment of the patients irritable bowel syndrome with constipation. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Vemlidy 25 mg for treatment of the enrollees hepatitis B virus. Findings:  The physician reviewer found that the Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with Viread, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. The patient had nausea with Viread requiring discontinuation, but may not experience the same effect with Vemlidy due to different concentrations of the prodrug and active drug forms of tenofovir in various tissues.  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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The representative of an enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the psychiatric services provided were not necessary for treatment of a psychiatric emergency medical condition. A psychiatric emergency consists of a patient who is an imminent danger to himself or to others. This can be due to a variety of things including, mania, psychosis, suicidal ideation with active plan, homicidal ideation, delusions, and delirium. In this case, the patient had ongoing chronic suicidal ideation. However, the patient did not have intent to act on suicidal ideation. In addition, the records do not show that the patient was in imminent danger to self. Moreover, IOP programs are not considered emergency psychiatric services. For the reasons provided, the patient did not receive psychiatric emergency medical services on the dates of service at issue.Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry with expertise 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.