Persius/hicric huggingface dataset:
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 for treatment of the enrollee who has a history of chronic lipid issues. Findings:  The physician reviewer found that The American College of Cardiology (ACC) has developed an expert consensus decision pathway (2016) regarding the role of non-statin therapies for LDL cholesterol lowering for management of atherosclerotic cardiovascular disease risk (ASCVD). There are several points, which are relevant to this case. The 2013 ACC/American Heart Association cholesterol guideline identified four major statin benefit groups for atherosclerotic cardiovascular disease risk reduction. According to these guidelines, the patient has an approximate estimated 10 year risk for ASCVD of 5% which does not even take into account her low level CRP result which has been shown to independently correlate with cardiovascular risk. Ezetimibe is the first non-statin medication that should be considered in most of the patient scenarios, given its safety and tolerability, as well as demonstrated efficacy when added to moderate dose statin in one trial of patients with acute coronary syndrome.  Bile acid sequestrants may be considered as second line therapy for patients in whom ezetimibe is not tolerated, but they should be avoided in patients with triglycerides over 300 mg/dl. Alirocumab and evolocumab may be considered if the goals of therapy have not been achieved on maximally tolerated statin and ezetimibe in higher risk patients with clinical ASCVD or familial hypercholesterolemia. Given the lack of long term safety and efficacy data on these agents, they are not recommended for use in primary prevention patients in the absence of familial hypercholesterolemia.  Given the patients overall low cardiovascular risk and absence of genetic data demonstrating familial heterozygous or homozygous hypercholesterolemia, the requested medication is not indicated. The records also do not demonstrate that the patient has been tried on  ezetimibe or a bile acid sequestrant. Therefore, Praluent 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 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: The parent of an enrollee has requested authorization and coverage for mastectomy to remove breast tissue for treatment of the enrollees gynecomastia. Findings: The physician reviewer found the submitted documentation supports the medical necessity of the requested services. The records document evidence of significant asymmetric gynecomastia that has been present for an extended period of time. This has affected him psychosocially as supported by his treating neuropsychologist. His work-up has included a history and physical examination, as well as excluding some of the more common etiologic sources. Based on the documentation provided, the patient has feminization of the breasts and marked breast enlargement consistent with grade IV gynecomastia. The American Society of Plastic Surgeons (ASPS) lists indications and recommendations for insurance coverage. Per ASPS, surgical treatment of gynecomastia in adolescents is recommended in the following settings: unilateral or bilateral grade II or grade III gynecomastia present which persists more than one year after pathological causes are ruled out; unilateral or bilateral grade IV gynecomastia present which persists more than six months after pathological causes are ruled out or persists after six months of unsuccessful medical treatment for pathological gynecomastia; and pain and discomfort due to the distention and tightness from the hypertrophied breast. Gynecomastia may cause considerable psychological distress, especially in adolescents who are struggling with issues related to sexual identity and self-image. This patient has evidence of grade IV gynecomastia that has been present for an extended time and has evidence of significant psychological distress directly related to his gynecomastia. Additionally, likely correctable etiologic sources have been ruled out. Thus, the medical evidence supports the requested services in this clinical setting. All told, the requested mastectomy to remove breast tissue is medically necessary for the treatment 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 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: An enrollee has requested authorization and coverage for fentanyl patch 12 mcg/1 hour, one patch every 72 hours, quantity of 10 patches for treatment of the enrollees neurofibromatosis and multifocal pain. Findings:  The physician reviewer found that review of the submitted documentation supports the medical necessity for the requested medication. Opioid medication may be considered as part of the standard of care when treating patients with chronic nonmalignant pain. Concern for opioid misuse can result in undertreatment of pain and opioids are frequently used because there are few alternative agents that offer the same level of analgesia. In support of prescribing opioids, controlled trials have shown a modest effect in terms of analgesia with opioids. Judicious prescribing and monitoring remains a viable option for selected patients. In this case, the patient presents with ongoing chronic nonmalignant pain and extended release morphine had been ineffective. There is no evidence of a violation of an opioid agreement or contract or refusal to participate in urine drug screening or completion of readily available tools used in the assessment of pain and function. There is no evidence of a treatment plan to provide another medication in the same class at an equivalent MED. For the reasons provided, the request for fentanyl patch 12 mcg/1 hour, one patch every 72 hours, quantity of 10 patches has been established as medically necessary for the treatment of the 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 physical medicine and rehabilitation 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: The parent of an enrollee has requested reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. On an initial evaluation, the patient reported chronic suicidal ideation and numerous suicide attempts. He reported other behavioral issues as well as problems with impulse control and numerous eating disorder symptoms. The patient reported relational issues with his family. During the disputed period, he reported suicidal thoughts. It does not appear that he was acting on these thoughts during that time. He often expressed resistance to treatment and was making minimal progress in his compliance with eating prescribed amounts. He expressed symptoms of depression as well as anxiety that continued regarding his weight gain. Based on the records, residential treatment was effective for the patient in terms of reducing suicidal ideation as well as reducing eating disorder symptoms. The medical evidence supports the services at issue in this clinical setting. All told, residential treatment center services were medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. 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 Guardant360 testing provided on 2/15/17 for evaluation of the enrollees non-small cell carcinoma. The patient presents with biopsy proven metastatic non-small cell lung cancer. In this clinical setting molecular diagnostic studies are considered the standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) guidelines for  non-small cell lung cancer strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, the Guardant360 gene testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 18 hours per week of direct applied behavioral analysis (ABA) therapy, two hours per month of parent training and 21 hours per month of supervision for a total of 77 hours for treatment of the enrollees autism spectrum disorder.Findings: The physician reviewer found that according to the documentation submitted for review, ABA therapy is medically necessary for this patient to address the decline in socialization and decreased interest in food. In addition, the provider reports that the patients level of function is higher when the patient is receiving ABA therapy. However, based on the clinical documentation submitted, the hours requested are excessive in this clinical setting. The documentation submitted for review does not demonstrate the patient has self-injurious behaviors, apart from decreased food intake. Based on the clinical documentation submitted for review, 10 hours per week of direct ABA therapy, two hours per month of parent training and 10 hours per month of supervision is medically necessary and appropriate for treatment of the patients autism spectrum disorder. Final Result: The reviewer determined that a portion of the requested services is 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 pediatrics and neurology with special qualification in child neurology 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 comprehensive day treatment, consisting of clinical therapies (occupational therapy, speech therapy, physical therapy, and psychotherapy), six hours per day, five times per week for treatment of the enrollee who has a history of traumatic brain injury. Findings:  The physician reviewer found that there is a lack of support in the medical literature of the requested services in this clinical setting. The patient is more than one year status post traumatic brain injury as noted in the records. The medical evidence indicates that most recovery occurs in the first six to 12 months. However, recovery can extend beyond one year and neurologic recovery continues for perhaps up to two years. In this patients case, based on the reported progress with the patients current treatment program, the patient appears to have reached a functional plateau consistent with the severity of his residual neurological deficits. The documentation provided does not support a reasonable expectation that this patient will show a measurable, practical improvement in his functional status within a reasonable period of time. As such, there is not a reasonable expectation that an intensive rehabilitation therapy program would significantly affect this patients condition when compared with therapy provided at a less intense level of care. The medical literature supports continued through a home exercise program with assistance from non skilled caregivers with intermittent skilled therapy oversight. A periodic reassessment of his neurological condition can be performed to determine the potential for measurable gains within a reasonable and predictable period of time and need for further skilled therapy at a higher level. Based on the records provide, this patient does not meet the criteria for the intensity of services being requested. Therefore, comprehensive day treatment, consisting of clinical therapies (occupational therapy, speech therapy, physical therapy, and psychotherapy), six hours per day, five times per week are not medically necessary for the treatment of this patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee's representative is requesting reimbursement for the proton beam radiation therapy provided for treatment of the enrollees metastatic lung cancer.Findings: The three physician reviewers found that there is currently a lack of medical literature to support that treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques for patients with metastatic disease. Standard treatment with photon radiation is associated with a very low risk of toxicity. Moreover, there is no data submitted that suggests that treatment with proton techniques will be able to improve sparing of the surrounding normal structures compared to standard photon techniques using intensity modulated radiation therapy. Consensus group guidelines from the National Comprehensive Cancer Network (NCCN) also do not support the use of proton therapy in this clinical setting. Based on these reasons, the proton beam radiation therapy provided was 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 services at issue were 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: The three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the UroLift prostatic urethral lift procedure for treatment of the enrollees benign prostatic hyperplasia (BPH). Findings: The three physician reviewers found the requested procedure is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The peer-reviewed literature including prospective sham controlled randomized studies have shown that the UroLift system is safe and effective in relieving lower urinary tract symptoms due to BPH (Roehrborn, et al). Given the support in the peer-reviewed literature, the request for UroLift prostatic urethral lift procedure is 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 procedure is 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 physician reviewers are board certified in urology and are actively practicing. The reviewer 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 Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodules. Findings:  The physician reviewer found that The physician reviewer 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. Afirma Gene Expression Classifier testing 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 the need for unnecessary surgeries.  Because it is 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. All told, Afirma Gene Expression Classifier testing provided on 3/17/17 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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.