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

Nature of Statutory Criteria/Case Summary: An enrollee has requested positron emission tomography (PET) for evaluation of the enrollees memory loss. Findings: Two physician reviewers found that the current data and research suggest that if Alzheimers disease is a clinical possibility based upon clinical history and cognitive testing including cerebrospinal fluid (CSF) evaluation, then a PET scan is the best imaging procedure to evaluate for this form of dementia. This patients records do not describe the level of subjective cognitive decline nor is there a record of mini mental examination (MME) testing or other cognitive analysis to provide clinical data that Alzheimers disease was a clinical possibility. The patients report that she has difficulty with memory is insufficient to support the use of this type of exam in this clinical setting. Therefore, the documentation provided in the records does not demonstrate that the PET scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: All three physician reviewers 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 Epclusa 400-100 mg tablets for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that According to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, Epclusa is recommended as first-line treatment for genotype 2 patients, based on clinical trials which showed superiority to Sovaldi with ribavirin, including in patients who have failed peg-interferon and ribavirin.  A delay in treatment may result in decreased survival.  All told, Epclusa 400-100 mg tablets are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested tumor treating fields (TTFields) therapy using Optune Plus transducer device for treatment of the enrollees glioblastoma.  Findings: Two physician reviewers found that a large multi-institutional prospective controlled trial randomized recurrent glioblastoma patients to chemotherapy or treatment with the Optune device. The device appeared to be as effective as chemotherapy and the authors concluded that no improvement in overall survival was demonstrated, however efficacy and activity with this chemotherapy-free treatment device appears comparable to chemotherapy regimens that are commonly used for recurrent glioblastoma (Stupp, et al). The most recent National Comprehensive Cancer Network (NCCN) guidelines support consideration of alternating electric field therapy for recurrent glioblastoma. Given this patients limited options for a rapidly progressing tumor, and data suggesting that TTFields for this patients recurrence is a potentially effective option, the TTFields therapy using Optune Plus forward was and is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the device at issue was and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested dental treatment for the build-up to tooth, post root canal for orthodontic needs. Findings: The physician reviewer found that the Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees tooth fracture.  The records document that the patient sustained dentoalveolar trauma. On follow-up with his provider, tooth number 9 was found to be necrotic and required endodontic treatment and build-up. In addition, tooth number 9 was malpositioned and orthodontic treatment was appropriate to restore it to its correct position. Thus, the treatment provided was within standard accepted guidelines. Orthodontic treatment to reposition the involved tooth into an ideal position was indicated and is a known sequela after such trauma. All told, the build-up to tooth, post root canal for orthodontic needs provided to this patient following the dentoalveolar trauma was medically necessary.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 oral and maxillofacial surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested testing for evaluation of the enrollees behavioral health condition.  Findings: The physician reviewer found that the testing was not medically necessary for evaluation of the patients medical condition. In general, the practice of pharmacogenetics, or the tailoring of a medication regimen based on an individuals genetic organization, may become a valuable tool in the treatment armamentarium for those plagued with psychiatric illness.  However, despite its promise, pharmacogenetics is not yet ready for mainstream clinical application. The American Psychiatric Association (APA) practice guidelines do not recommend genetic testing for cases involving routine medication management. Additionally, Severino and colleagues state that The search for molecular predictors of treatment response in [bipolar disorder] has so far produced limited evidence towards the involvement of specific genes in predicting response to treatments. While these findings are promising, they cannot constitute reliable markers with acceptable sensitivity and specificity that could be implemented in clinical settings. In this case, aripiprazole is a second-generation antipsychotic recommended for manic, hypomanic or mixed episodes. The data supporting aripiprazole for bipolar maintenance and bipolar depression are less robust. Considering the sub-therapeutic dosing of 5 and 10 mg daily and the patients history of nonadherence, the aripiprazole trial was inadequate by the date of the testing. The lamotrigine was adequately dosed but the medication is commonly titrated up to 400 mg daily for bipolar illness. Moreover, the patient had not yet exhausted standard mood stabilizing medications like lithium, lurasidone and olanzapine, while the dosing, duration and outcome of the quetiapine, and to a lesser extent the risperidone, were not presented. Additionally, outcome of evidence-based psychotherapies, such as cognitive behavioral therapy, interpersonal and social rhythm therapy and family therapy, or social-cultural-spiritual community activities, were not documented. Considering the relevant peer-reviewed literature and current practice standards, the disputed testing would not have been expected to yield information that significantly influenced treatment decisions, improved the patients condition, or prevented a more serious episode of illness. Accordingly, the testing at issue was not medically necessary for evaluation of the patients behavioral health condition.Final Result: The reviewer determined that the testing at issue was 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 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 radiofrequency neurolysis of the bilateral sacroiliac (SI) joints for treatment of the enrollees low back pain.  Findings: Three physician reviewers found that Radiofrequency neurolysis of the bilateral SI joints has not been established in the peer reviewed literature as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Manchikanti and colleagues published an evidence based review of SI joint interventions and stated evidence for SI joint interventions are limited for conventional radiofrequency neurotomy. In addition, Patel and colleagues conducted a randomized controlled trial and found that less than half (38%) of the patients benefited from radiofrequency lesioning at six months. At this time, more research is needed on the efficacy of radiofrequency neurolysis for the treatment of SI joint pain. As such, radiofrequency neurolysis of the bilateral SI joints is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested procedure 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 physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested LINX procedure for treatment of the enrollees gastroesophageal reflux (GERD).  Findings: Two physician reviewers found that appropriate patient selection is crucial before anti-reflux procedures. In prelude to surgical intervention for GERD, it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and work-up of GERD, and no single test alone can provide the entire clinical picture (Jobe, et al). This patient has undergone some of the required evaluation. Although this patient has GERD as predicated on her development of Barretts esophagus, it appears she has benefited at least 75% from acid suppression treatment, and as such cannot be considered medically refractory to acid-blocker drugs. Also, implantation of LINX in this patients clinical setting must be approached with caution since the device is not U.S. Food and Drug Administration (FDA) approved for use in patients with documented Barretts esophagus. All told, the requested LINX procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested procedure 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for eight weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials. All told, Harvoni for eight weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment for treatment of the enrollees polysubstance abuse. Findings: The physician reviewer found that the 12 days of residential treatment were medically necessary for treatment of the patients medical condition. In this case, the patient was unable to maintain sobriety in the outpatient setting. Drug use including heroin, cannabis, alcohol and benzodiazepines, dominated his daily routine, permeated all functional domains and jeopardized his well-being. His peer group, social interactions and family dynamics were not conducive to clean and sober living. He was deemed to be at high risk for relapse. He had significant psychiatric co-morbidity and a poorly defined self-concept. According to the documentation from the treatment facility, the patient was actively engaged in appropriate services, including family sessions, group therapy and discharge planning efforts. Further, the patients insomnia and craving were both addressed with pharmacotherapy. In addition, the treatment capitalized on the patients ambivalence to mobilize the individual towards the preparation and action stages of recovery, and, facilitated a seamless transition to community-based programming. Based on the longitudinal history and medical documentation, the patient would have likely relapsed and required re-admission in the absence of the disputed residential programming. The services at issue were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards. Moreover, the services provided were for active treatment, and reasonably expected to bolster his resilience, improve his condition and prevent a more serious episode of illness. Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically necessary for treatment of the patients behavioral health condition.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 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 Cialis 5 mg for treatment of the enrollees erectile dysfunction. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The phosphodiesterase inhibitor potential to prolong QT interval and adversely interact with use of ziprasidone to potentiate cardiac arrhythmia is a theoretical risk not reported in the ambulatory setting.  Additionally, this is a risk which can be monitored by electrocardiogram and other techniques to assure early detection.  While the risk has been discussed with Levitra, it has not been discussed with Viagra.  Both Levitra and Viagra have been offered by the Health Plan.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested Cialis 5 mg is not medically indicated 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder (ASD).  Findings: The physician reviewer found that the request for 19.5 hours per week of direct ABA therapy and 10 hours per month of supervision has not been established as medically necessary for treatment of the patients ASD. Remington and colleagues indicate that autistic children who are responsive to ABA therapy will do so within two years of the onset of therapy. The medical literature also shows that for older autistic children, the direction of therapy is to decrease ABA hours in favor of group and social activities to increase the patients social and community skills (Reichow, et al; Matson, et al). This patient has been receiving intensive ABA therapy from the same provider for more than three years with only modest improvements in most recorded parameters, but he is still having significant issues with health related matters and repetitive behaviors. In this clinical setting, a reduction of the ABA hours is medically reasonable. The Health Plans authorization of 60 hours per month of direct ABA therapy, six hours per month of supervision and two hours per month of parent training is medically appropriate for treatment of the patients ASD.  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 pediatrics with sub-specialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings: Three physician reviewers found that this patient has treated diabetes and hypertension. The patient is currently on Vytorin therapy and simvastatin 20 mg with ezetimide. The patient has had multiple advanced lipid profile testing in the past as well. In situations where there is moderate cardiovascular risk and additional clinical risk factors are present, a single measurement of advanced lipid parameters may be useful in deciding whether to start lifelong statin lipid lowering therapy. However, in this instance, the patient already has an indication for high dose statin therapy based on her age, treated diabetes, hypertension and the current American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines (Greenland, et al). In addition, her low density lipoprotein cholesterol (LDL-C) and high density lipoprotein (HDL) are also being followed as well. There is a lack of data or published guidelines to suggest that ongoing repeated measurements of these advanced lipid profile values provide either prognostic or additional clinical value as opposed to the current risk factor based guideline medication regimens. All told, based on current published ACCF/AHA guidelines and published data, repeated advanced lipid profile monitoring does not provide additional actionable clinical information compared to standard profiles and risk assessments (Stone, et al; Mora, et al). Thus, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.Final Result: Three reviewers determined that the testing at issue was 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: All three physician reviewers 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.