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

Nature of Statutory Criteria/Case Summary:The enrollee has requested reimbursement and prospective authorization and coverage for continued residential treatment center (RTC) services provided. Findings:  The physician reviewer found that the admitting provider noted that the patient was low risk for withdrawal. He was placed on naltrexone. His vital signs were stable. He was not a danger to himself or others, and did not demonstrate self-injurious behaviors. There were no emotional, behavioral, cognitive, or impulsive symptoms requiring RTC level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. He had multiple comorbid medical problems, however these are chronic in nature and do not require monitoring on a 24-hour basis. The same applies to his history of depression and anxiety. He has been described as motivated and appears to be working the program. The medications, detoxification, medically assisted treatment, and any changes to same, also did not and do not require RTC level of care as these are safely and adequately addressed in an ambulatory setting. Although the patient requires treatment to help develop coping skills and work on relapse prevention, this does not require the structured environment of a RTC setting. Relapse risk is inherent among this patient population and is not a reason to continue treatment at this level of care. His treatment could have been provided at an ambulatory level of care. Thus, the RTC services provided were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not and 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 with sub-specialty certification in addiction 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: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for 12 weeks for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting. 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients with HIV coinfection should be treated with regimens including Zepatier for 12 weeks. The guidelines now state that lack of NS5A resistance testing should not be an impediment to coverage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 authorization and coverage for MiniMed 670G insulin pump. Findings:  The physician reviewer found that the Medtronic MiniMed 670G system was approved by the U.S. Food and Drug Administration with the following description: The Medtronic MiniMed 670G system is intended for continuous delivery of basal insulin (at user selectable rates) and administration of insulin boluses (in user selectable amounts) for the management of type 1 diabetes mellitus in persons, fourteen years of age and older, requiring insulin as well as for the continuous monitoring and trending of glucose levels in the fluid under the skin. The system is the closest to an automated closed loop system device for insulin delivery in the management of diabetes mellitus type 1. Leelarathna and colleagues have shown that closed-loop insulin delivery at home reduces mean glucose and increases time in target without increasing the risk of hypoglycemia in adults with relatively well-controlled type 1 diabetes.  In addition, studies are also demonstrating the deleterious effect of wide glucose fluctuations as a factor in the development of diabetes related complications. This patient has neuropathy, so it is important to bring her hemoglobin A1c to 7% with no hypoglycemia. Microvascular complications may be prevented or delayed if the hemoglobin A1c can be maintained at 7% or less with no hypoglycemia. As such, an automated insulin delivery device would assist in managing and controlling these wide glucose fluctuations. Moreover, this patient has retinopathy and neuropathy, so this feature is important. The MiniMed 670G is a closed loop system insulin pump with continuous glucose monitor that will automatically make corrections when the patient is trending to hypoglycemic or hyperglycemic range. This system will allow the patient to remain within the recommended target range, most of the time. With this system, the continuous glucose monitoring will communicate with the pump. The patient will be able to keep hemoglobin A1c closer to goal and while minimizing hypoglycemic and hyperglycemic events. The MiniMed 670G is a diabetes management device that utilizes advanced technology. As such, MiniMed 670G insulin pump is likely to be more beneficial than any other available therapy for the management of this patients diabetes type 1. Final Result: Two of the three reviewers determined that the requested device 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 are  board certified in in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zelboraf (vemurafenib). Findings:  The physician reviewer found that The request for Zelboraf is medically necessary for treatment of the patients medical condition. BRAF is an important signal transduction protein that signals within the same pathway as KRAS and EGFR, which are frequently overexpressed or mutated in colon cancer. Zelboraf is a specific inhibitor active against the BRAF V600E mutant protein that was present in this patient. Although there was not much single agent activity in phase II studies, the studies did show efficacy when combined with chemotherapy . A study of 86 patients where the progression-free survival (PFS) on regimen selected by molecular profiling was compared to PFS on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This trial has significant results for patients with stage IV tumors. As such, results from molecular profiling offers a rational selection of the next regimen. For the reasons provided, treatment with Zelboraf has been established as medically necessary for 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 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: The patients parent has requested authorization and coverage for Humatrope 12 mg cartridge. Findings:  The physician reviewer found that cccording to both the American Association of Clinical Endocrinologists and the Pediatric Endocrine Society, sustained postnatal growth failure in children who have been SGA is considered an indication for growth hormone treatment. SGA causes a pathophysiologic process in utero that adversely affects fetal growth. Treatment with growth hormone in children with SGA usually stimulates substantial catch-up growth during the first two years of treatment, followed by a slower but constant increase in growth. GH treatment regimens prescribed for children with SGA have a reassuring safety profile. The records document that this patient has a history of SGA with failure to catch up in growth, which is a standard indication for GH therapy. Her pre-treatment height was below the third percentile for age, and her height velocity improved on GH therapy. Although her height is now at the eighth percentile, she is at the age of pubertal development and her bone age is advancing, resulting in an adult height prediction that is more than 2.25 SDs below the mean for U.S. adult females. Resumption of GH therapy is medically necessary to improve height velocity to achieve a normal adult height, and there is a limited time window to intervene while the patients puberty is advancing. Given this support, the requested Humatrope 12 mg cartridge is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology 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 Lenvima 10 mg capsule. Findings:  The physician reviewer found that the request for Lenvima 10 mg capsule is  medically necessary for treatment of the patients medical condition. The patient presents with metastatic hepatocellular carcinoma with progressive disease. The phase III SHARP trial shows that sorafenib treatment may result in survival advantage over supportive care alone by three months. Capecitabine has a response rate of 25% in one study where it was used as a single agent . Most cytotoxic chemotherapies have comparable response rates when tried against hepatocellular carcinoma, a typically chemo-resistant tumor ). Lenvima is a multi-functional tyrosine kinase inhibitor with activity against VEGFR. Phase I and II trials have shown safety and efficacy against hepatocellular carcinoma . As such, Lenvima is a reasonable next step therapy and medically necessary for treatment of the patients hepatocellular carcinoma. 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 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 a nerve block and jejunostomy tube for treatment of the enrollees chronic pancreatitis. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Celiac plexus nerve block is a safe and effective therapy for pain caused by non-malignant chronic pancreatitis. Celiac plexus block is an effective therapy for chronic abdominal pain due to a number of causes, as the plexus provides sensation information from the liver, pancreas, spleen, omentum, and alimentary tract to the mid-transverse colon, adrenal glands, and kidney. A celiac plexus block can decrease the need for opioid medications. A celiac plexus block is a safe method to control abdominal pain unresponsive to medical treatments in patients with benign disease.  Jejunostomy tube placement is also supported for this patient with chronic pancreatitis. Oral or gastric feeding increases demand on the pancreas, whereas jejunal feeding does not. Therefore, jejunal feeding is useful in chronic pancreatitis complicated by malnutrition and by limitation of oral intake due to pain. Additionally, jejunostomy tubes are more stable than percutaneous gastrostomy tubes with jejunal extension. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the requested medication Euflexxa for treatment of the enrollees knee pain. Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting. The evidence-based, peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. Viscosupplementation has been found to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with bone-on-bone osteoarthritis of the left knee and presents with recurrent left knee pain. Clinical examination findings are consistent with knee osteoarthritis. She has received prior series of Euflexxa injections, with significant pain reduction for six months. She has reportedly failed medications, corticosteroid injections, and physical therapy. The use of Euflexxa is reported to delay total knee replacement due to her young age. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the oral appliance (E0486) provided.   Findings:  The physician reviewer found that given the body of evidence to support the use of oral appliance therapy, the device at issue was effective in the treatment of this patients OSA. While the guidelines recommend CPAP as the first line therapy for patients diagnosed with OSA, they acknowledge that not all patients are tolerant of CPAP.  In that setting, it is generally a standard practice to use alternative therapies to CPAP for patients with OSA who do not tolerate or respond to CPAP. According to recently published joint practice guidelines between the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep (AADSM) Medicine, the professional societies have stated: We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. Other literature reviews have reached similar conclusions on the net utility/efficacy of oral appliance therapy.  A study performed a systematic review and meta-analysis of five studies assessing the effectiveness of an oral appliance for the treatment of obstructive sleep apnea. They found that an oral appliance decreased the apnea hypopnea index as compared with a sham device. Oral appliance therapy has been shown to have a higher degree of efficacy when compared to many surgical interventions for OSA .  Based on the published evidence available to date, the oral appliance (E0486) was likely to have been more beneficial than any available treatment method for the treatment of this patients medical condition.Final Result: All three reviewers determined that the device at issue was 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 number one is board certified in internal medicine with sub-specialty certification in pulmonary disease with expertise in sleep medicine and is actively practicing. Physician reviewer number two is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing. Physician reviewer number three is board certified in oral facial and maxillary surgery with expertise in surgical treatment of obstructive sleep apnea and is actively practicing. All three 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 enrollee has requested authorization and coverage for progesterone capsules, testosterone cream and Biest estriol capsules for treatment of the enrollees menopausal symptoms, allergic sensitivities and interstitial cystitis. Findings:  The physician reviewer found that the request for progesterone capsules, testosterone cream and Biest estriol capsules are not medically necessary for treatment of the patients medical condition. According to the American College of Obstetricians and Gynecologists Committee on Gynecologic Practice and the Practice Committee of the American Society for Reproductive Medicine, Evidence is lacking to support superiority claims of compounded bioidentical hormones over conventional menopausal hormone therapy. Practice guidelines further state that Customized compounded hormones pose additional risks. These preparations have variable purity and potency and lack efficacy and safety data. Because of variable bioavailability and bioactivity, both underdosage and overdosage are possible. Conventional hormone therapy is preferred over compounded hormone therapy given the available data. In general, bioidentical hormones are not the standard of care or recommended. Furthermore, there is a lack of sufficient documentation describing the patients past medical, surgical or gynecological history that would support the medical necessity for alternative therapy. Final Result: The reviewer determined that the requested medications 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 obstetrics and gynecology 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 reimbursement for the carotid duplex scan. Findings:  The physician reviewer found that based on the records provided the patient presented with some coronary risk but no documented symptoms suggestive of any neurologic condition, no documented neurologic abnormalities on physical examination and no documented carotid bruits. In this circumstance of no symptoms or findings suggestive of carotid disease a screening carotid ultrasound is not medically necessary and not the standard of care. Current guidelines endorsed by U.S. Preventive Services Task Force also do not consider screening carotid ultrasounds appropriate in asymptomatic patients. For the reasons provided, the carotid duplex scan performed was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service 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 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.