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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan with computed tomography (CT) for attenuation of whole body. Findings:  The physician reviewer found that Sarcomas are tumors that are known to have highly variable characteristics resulting in highly variable responses to treatment and therefore clinical outcome. Park and colleagues note that uterine leiomyosarcoma is an especially rare and aggressive malignancy with poor prognosis. Jackson and colleagues report that PET/CT allows for accurate evaluation of sarcoma patients. PET/CT is useful for management of patients with previously treated leiomyosarcoma and is highly effective in detecting recurrence in asymptomatic patients as follow-up post treatment as well as in settings where recurrence is suspected clinically. In this case, the patient is at a high risk for recurrence as she previously had axillary metastases, and PET/CT is being utilized as surveillance to monitor for recurrent disease. As PET/CT is highly effective in detecting metastatic disease before it may become clinically apparent, the results of the PET/CT would affect this patients clinical management. Therefore, PET scan with CT for attenuation of whole body is likely to be more beneficial for evaluation of the patients condition than any available standard therapy.Findings:  Two of the three physician reviewers found the requested PET scan with CT for attenuation of whole body 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 service 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: Physician reviewers 1 and 3 are board certified in diagnostic radiology and are actively practicing. Physician reviewer 2 is diagnostic radiology with sub-specialty certification in neuroradiology 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 authorization and coverage for Tibsovo (ivosidenib tablet 250 mg).Findings:  Two of the three physician reviewers found the requested Tibsovo (ivosidenib tablet 250 mg) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The U.S. Food and Drug Administration (FDA) does not list anaplastic astrocytoma as an indication for the use of ivosidenib. The National Comprehensive Cancer Network (NCCN) guidelines on central nervous system cancers do not mention ivosidenib as a treatment option in this clinical setting. Tibsovo is the subject of ongoing clinical trials. In this case, the requested medication is not likely to be more beneficial than standard therapy with procarbazine, lomustine and vincristine (PVC) or with temozolomide. Therefore, Tibsovo (ivosidenib tablet 250 mg) is not likely to be more beneficial for treatment of the patients condition than any available standard therapy.Final Result: The reviewers determined that the requested medication 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: Physician reviewers 1 and 2 board certified in internal medicine with sub-specialty certifications in medical oncology and in hematology and are actively practicing. Physician reviewer 3 is board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Nurtec 75 mg disintegrating tablets. Per the American Headache Society (AHS), calcitonin generelated peptide monoclonal antibodies (CGRP mAbs) are biologic agents that have demonstrated efficacy, safety, and tolerability for the preventive treatment of episodic and chronic migraine in phase 2 and phase 3 randomized, placebocontrolled trials. The U.S. Food and Drug Administration (FDA) has approved Nurtec ODT, an orally administered CGRP receptor antagonist, for the acute treatment of migraine with or without aura in adults and preventive treatment of episodic migraine in adults. The FDA approved Nurtec based on results of a randomized, double-blind, placebo-controlled trial by Croop and colleagues. The authors found that when taken every other day, Nurtec was effective for preventive treatment of migraine without unexpected or serious safety issues noted. In this case, the patient has a history of migraines. She is not an ideal candidate for treatment with many standard preventative medications due to her medical history. Moreover, treatment with Nurtec has resulted in improvement in the frequency of the patients migraines to near resolution. For these reasons, the requested Nurtec 75 mg disintegrating tablets are medically necessary for treatment of this patient.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 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 reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that the records provided for review document that this patient has a family history of coronary artery disease and diagnoses of mixed hyperlipidemia, low high-density lipoprotein (HDL) cholesterol, mild obstructive sleep apnea (OSA), low serum vitamin D, elevated liver enzymes, and essential hypertension. The patient underwent evaluation with advanced lipoprotein testing. In this circumstance, guidelines for the management of cardiac risk established by the American College of Cardiology (ACC) and American Heart Association (AHA) do not support routine advanced lipoprotein testing (Stone, et al.). These guidelines currently do not recommend performance of specialized tests in the context of assessing coronary risk including lipoprotein associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL) cholesterol, HDL cholesterol subclasses, lipoprotein (a), and homocysteine. In addition, treatment changes or additions based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings: Three of the three physician reviewers found the advanced lipoprotein testing was not likely to be more beneficial for evaluation 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 evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer 1 is board certified in internal medicine with subspecialty certifications in cardiovascular disease and adult congenital heart disease and is actively practicing. Physician reviewer 2 is board certified in internal medicine with subspecialty certification in cardiovascular disease and is actively practicing. Physician reviewer 3 is board certified in internal medicine with subspecialty certification in cardiovascular disease 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for implantation of vagus nerve stimulation (VNS) device. In this case, the patient meets the criteria for treatment-resistant depression since she has failed treatment with numerous antidepressants with appropriate adjunctive medications, as well as electroconvulsive therapy (ECT) and psychotherapy. The patient has been in the current depressive episode for five years with little improvement despite exhaustion of standard treatment options. Based on the treatment guidelines and the available evidence, vagus nerve stimulation (VNS) is the next appropriate step in the treatment of this patients refractory depression. Bottomley and colleagues concluded that their comprehensive summary of VNS with treatment as usual (TAU) for patients with treatment resistant depression supports that this treatment provides improving benefit and hope for this very hard-to-treat chronic population. Given these findings, the requested implantation of VNS device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Two of the three physician reviewers found the requested implantation of VNS device 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 services are 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: Physician reviewer 1 is board certified in psychiatry and is actively practicing. Physician reviewer 2 is board certified in psychiatry and is actively practicing. Physician reviewer 3 is board certified in psychiatry 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for inpatient hospital services. Merrill and colleagues report that the average length of stay nationwide for the treatment of humeral shaft fractures is three nights. Putnam and colleagues report that patients being treated for humeral shaft fractures often require several days of inpatient hospital stay. In this case, the patient sustained a humeral shaft fracture and remained hospitalized to facilitate early fixation and mobilization. The patients hospital course included pain control, risk stratification for surgery, evaluation and surgery by a specialized surgeon, and postoperative skilled therapy and pain control. Therefore, for inpatient hospital services were medical 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 orthopedic 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: The patient has requested authorization and coverage for epidural steroid injection at L5-S1. Helm Ii and colleagues report that transforaminal epidural steroid injections may provide significant benefits for patients with radiculopathy. In this case despite the presence of a diagnosis of lumbar radiculopathy, the records do not document objective evidence of active radiculopathy, noted no benefit from prior epidural steroid injections, and did not provide a rationale for a repeat injection in the face of limited previous benefit. Therefore, an epidural steroid injection at L5-S1 is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for  vitamin D screening. Findings:  The physician reviewer found that  The vitamin D receptor is expressed in multiple cells of the body including beta cells and cells involved in immune modulation and most organs in the body including the brain, heart, skin, and prostate. A causal role of vitamin D for bone health has been well established, as vitamin D deficiency is the cause of most cases of rickets and osteomalacia (Bouillon, et al.). In addition, studies have often suggested a link between vitamin D deficiency and conditions such as type 1 and type 2 diabetes, connective tissue disorders, inflammatory bowel disorders, and respiratory infections (Marino, et al.). This patient underwent vitamin D testing due to a history of low vitamin D levels and living in an area that is endemic for low vitamin D levels. As noted in the medical literature, vitamin D deficiency can be related to comorbid conditions and requires appropriate management. Given this patients history of low vitamin D levels and domicile in a region known for vitamin D deficiencies, the vitamin D screening was medically necessary for this patient. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with subspecialty 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: The patient has requested authorization and coverage for Remicade 600 mg every four weeks. The submitted documentation supports the medical necessity of the requested medication regimen. The U.S. Food and Drug Administration (FDA) approves the use of Remicade for the treatment of ulcerative colitis. Gibson and colleagues note that an intensified infliximab dosing strategy in response to clinical or laboratory signs of breakthrough inflammation may be required to produce a more therapeutic effect. Dumitrescu and colleagues note that infliximab dose doubling to 10 mg/kg led to short-term and long-term event-free survival in patients with ulcerative colitis, who had a loss of response to infliximab, in greater than 50% of the cases. Reinisch and colleagues report in a study of adults with moderate-to-severely active ulcerative colitis that long-term treatment with infliximab for up to three additional years was effective and well tolerated. The American College of Gastroenterology (ACG) guidelines on the treatment of ulcerative colitis support increasing the infliximab dosage in patients with uncontrolled disease. The American Gastroenterological Association (AGA) guidelines for management of ulcerative colitis support increasing the infliximab dosage in patients with a low infliximab level, as in this case. AGA guidelines on therapeutic drug monitoring in inflammatory bowel disease note that an infliximab dose increase is needed when there is a low drug level. In this case, the patient has uncontrolled clinical disease, and a history of inflammation on colonoscopy with the current dosage, placing the patient at risk for colorectal cancer and severe disease flare. Continuing with the current dosage may lead to risk for a disease flare requiring hospitalization or surgery, uncontrolled disease, or uncontrolled disease manifesting as dysplasia and leading to colon cancer. In this clinical setting, the requested medication regimen is medically indicated. Remicade 600 mg every four weeks is medically necessary to prevent disease, disability, and other health conditions or their progression; to prolong life; to promote physical and mental health and efficiency; and to correct or ameliorate any physical or behavioral conditions. Therefore, Remicade 600 mg every four weeks is medically necessary 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for computed tomography (CT) scan of the chest and CT scan of the abdomen. The available records state that this patient presents with a short history of night sweats and weight loss. The patients night sweats have a possible alternative diagnosis in menopause, which should be further considered and ruled out. Per Gaddey and Holder, the patients weight loss does not meet the criteria for the diagnosis of unintentional weight loss in an adult. Per the authors, the definition of unintentional weight loss as greater than 5% loss of a persons weight over the course of six to 12 months. The records do not document the extent nor duration of weight loss to support a diagnosis of unintentional weight loss. In addition, the patients laboratory examinations do not suggest hematologic malignancy. With hematologic malignancy, the lymph cells which become malignant are frequently elevated on a blood test. When the bone marrow is overwhelmed by the growth of these lymph cells or if there is hemolytic stress, patients may have concomitant low red blood cell counts and/or low platelets (Arber, et al.) The patients blood test did not demonstrate elevation in white blood cells, anemia, or thrombocytopenia. The patients urinalysis revealed the possibility of urinary tract infection given the presence of bacteria and elevated WBC esterase. An infection could cause or contribute to the patients night sweats. Moreover, the patient is the appropriate age for menopause, and night sweats can present in the premenopausal, perimenopausal, or postmenopausal stages. Avis and colleagues found that patients who experience night sweats prior to changes in period frequency have the longest duration and most severe night sweats. The patients continued periods do not exclude hot flashes as a cause for her night sweats. Given the presence of plausible alternative diagnoses that require further work-up without imaging, the requested CT studies are not indicated for evaluation of this patient. For these reasons, the requested CT scan of the chest and CT scan of the abdomen are not medically necessary for this patient. Final Result: The reviewer determined that the requested services are 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 neuroradiology with subspecialty certification in diagnostic radiology 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 Xifaxan 550 mg tablets. The records document that this patient has symptoms consistent with small intestinal bacterial overgrowth. The patients provider has recommended treatment with Xifaxan. As noted in the medical literature, Xifaxan has been demonstrated to be highly effective in the treatment of patients with small intestinal bacterial overgrowth for eradication of bacteria and symptom relief (Gatta and Scarpignato). The medication has been found to have greater effectiveness with fewer side effects than antibiotic alternatives with results that are sustained for several weeks after treatment. More recent studies have corroborated these findings (Boltin, et al.; Barkin, et al.). Xifaxan has emerged as the preferred agent among providers for the treatment of small intestinal bacterial overgrowth over alternatives (Achufusi, et al.). Since this patient has symptoms consistent with small intestinal bacterial overgrowth, treatment with Xifaxan is appropriate. All told, the requested Xifaxan 550 mg tablets are medically necessary for treatment of this patient. 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 subspecialty 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.