Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Harvoni 90/400 mg 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation for evaluation of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to support the requested services in this clinical setting. The patients provider had noted that TMS is appropriate if the patient had a failure to respond to several evidenced based augmentation therapies. However, there is no documentation that the patient received any augmentation therapies. He received monotherapy with sertraline, Effexor, Prozac, and Lexapro. The record does not show that this patient has been augmented with mirtazapine, lithium, bupropion, or thyroid hormone which are the augmentation medications. The patient is currently on lamotrigine 300 mg for the treatment of his depression. The provider also reported that the patient has major depressive disorder and not dysthymia or bipolar disorder. Lamotrigine for the treatment of unipolar depression is considered off label use. It is likely that the patient is receiving benefit from lamotrigine due to emotional dysregulation that could be from a personality disorder or unresolved trauma. The records do not support that this patient has been adequately trialed with depression augmentation strategies. As such, TMS therapy would not be clinically justified at this time until augmentation strategies for the treatment of this patients depression have been performed. 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 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 reimbursement for Guardant360 test for evaluation of the enrollees non-small cell lung cancer. Findings:  Two physician reviewers found that The National Comprehensive Cancer Network Guidelines for non-small lung cancer, version 1.2018 state that adequate tissue is needed for molecular testing. If there is no available tissue, plasma testing can be done such as Guardant360. In this case, there is adequate tissue as evidenced by the reading of the pathology report and the FoundationOne testing performed. BRAF, ALK, EGFR, MET, RET, ERBB2, PDL1, ROS-1 can be performed on tissue. The development of liquid DNA assays and their implementation into clinical practice is a valuable option in cases where tissue quantity is inadequate for mutation testing or in patients who refuse or are unable to undergo biopsy. The medical literature does not support the superior efficacy of this testing in this clinical setting. Accordingly, Guardant360 laboratory testing was not likely to have been more effective than the available options of evaluating this patient. 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient presented with increased cardiovascular risk.  In this circumstance guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), CRP, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition 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. Even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided 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 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: Reviewers 1, 2 and 3 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for clindamycin infusion for treatment of the enrollees connective tissue disease and scleroderma. Findings:  The physician reviewer found that currently, the treatment of scleroderma or systemic sclerosis involves organ specific therapy. The current medical literature fails to support the treatment of scleroderma with clindamycin. The medical literature for minocycline and scleroderma reveal that this medication is ineffective in the treatments of systemic sclerosis. The authors found that the change in the MRSS (Modified Rodnan skin thickness score) was similar to that expected in the natural course of this disease. Based on these data, minocycline is not an effective therapy for systemic sclerosis. Researchers reported that rituximab improved patient health outcomes when compared to matched control groups. The authors concluded that rituximab demonstrated improvement of skin fibrosis and prevention of worsening lung fibrosis, supporting the therapeutic concept of B cell inhibition in systemic sclerosis. In this case, the patient has active lung disease and skin disease, overlap disease. The current literature supports rituximab therapy for the treatment of overlap syndrome. In addition, in patients with interstitial lung disease, rituximab prevented significantly the further decline of FVC compared with matched controls. Overall, the literature does not support clindamycin as a recommended therapy for the treatment of scleroderma and overlap syndrome. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for Cell Enumeration and ID for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  Three physician reviewers found that as noted in the peer-reviewed medical literature, circulating tumor cell (CTC) testing has demonstrated to effectively evaluate patients with breast cancer as a biomarker for response. Several clinical trials have shown that CTC has prognostic utility in determining overall survival and progression free survival in patients with breast cancer. One large randomized clinical trial has shown similar findings in patients with metastatic prostate cancer but further studies are needed before the test is considered a routine part of evaluation and treatment in this clinical setting. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a referral to an acupuncturist for treatment of the enrollees abdominal pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. The use of acupuncture for the treatment of chronic abdominal pain is not supported in the peer-reviewed literature. In addition, the documentation submitted for review does not demonstrate the total number of acupuncture sessions completed or reports of any sustained, significant, objective functional improvement. Therefore, based on the lack of peer-reviewed literature supporting the use of acupuncture for ovarian cysts and absence of documentation demonstrating either medication intake reduction, or function activities of daily living improvement with prior acupuncture, the request for a referral to an acupuncturist is not supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested referral 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 oriental 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  Three physician reviewers found that based on the submitted records, this patient presented with increased coronary risk and coronary artery disease.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk, including lipoprotein-associated phospholipase A2, myeloperoxidase, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine. Treatment change or addition 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. Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other available options for evaluating this patient. 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: Reviewers 1, 2 and 3 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the wearable cardioverter defibrillator for treatment of the enrollees myocardial infarction (MI). Findings:  Two physician reviewers found that in this circumstance, there is potential for recovery of left ventricular ejection fraction (LVEF) over time with medical therapy. In addition, there was no documented indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, unexplained syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least 90 days have elapsed with continued left ventricular dysfunction demonstrated by an ejection fraction less than 35% despite appropriate treatment. A prophylactic defibrillator before this time has not been demonstrated to improve outcome. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not been met are largely comprised of registry data without adequate control groups. At this time, a prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, or required explantation. For these reasons, the wearable cardioverter defibrillator 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 device at issue was 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for the prostate cancer test (CPT code 84999).Findings:  The physician reviewer found that this patient underwent genomic and protein biomarker testing (Oncotype DX) to help in clinical decision making. Testing was done to further evaluate risk of disease progression and prognosis. Molecular and genomic testing at this time appears to be helping patients with low risk disease to make decisions regarding observation versus treatment. However, there are drawbacks to this testing which include heterogeneity of prostate cancer and uncertainty of potential clinical benefit. While this particular testing can be helpful in both low and high risk patients, further studies are needed to evaluate its benefits over the available standard options. Furthermore, considering this patients Gleason score of 3+3/10, his prostate specific antigen score of 6.4 and a low volume of cancer detected, the American Urology Association guidelines would have placed this patient at a low risk without performing genomic testing. In conclusion, genomic testing although promising is investigational and its clinical benefit remains unclear. All told, the prostate cancer test (CPT code 84999) was not likely to have been more effective than the available standard options of evaluating this patient. Final Result: Two of the three 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 reviewers 1, 2 & 3 are board certified in urology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the functional endoscopic sinus surgery (FESS) for treatment of the enrollees chronic pansinusitis, septal deviation, bilateral nasal valve collapse, bilateral inferior turbinate hypertrophy and dysphagia. Findings:  The physician reviewer found that the FESS provided was not medically necessary for treatment of the patients medical condition. While sinus ostial dilation can be an appropriate therapeutic option for patients with chronic sinusitis and recurrent acute sinusitis, the criteria have not been met in this patient. The American Academy of Otolaryngology  Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis (CRS) as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. CRS is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain or pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. And the AAOHNSF defines recurrent acute sinusitis as four or more recurrent episodes of acute rhinosinusitis with complete clearing of symptoms between episodes over a one year period. In this case, CRS was not documented in this patient. There was no documentation of 12 weeks of consecutive disease. Recurrent acute sinusitis was also not documented in this patient. There was no documentation of four or more recurrent episodes over a one year period. There was no documentation of chronology of disease, symptoms or treatment. There was no documentation that he was treated with maximal medical therapy prior to the CT scan. The AAOHNSF defines maximal medical therapy as: oral antibiotics of two to four weeks duration for patients with CRS, systemic and/or topical steroids, saline irrigations, topical and/or systemic decongestants, treatment of concomitant allergic rhinitis, including avoidance measures, pharmacotherapy, and/or immunotherapy. There was only CT evidence of sinus disease in the maxillary sinuses and right anterior ethmoids. The posterior ethmoids, frontal and sphenoid sinuses were normal. There was no documentation of findings of nasal endoscopy suggestive of sinus disease. Therefore, sinus surgery was not medically necessary in this case. Final Result: The reviewer determined that the surgery at issue was 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 otolaryngology and 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.