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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove and/or repair hernia mesh for treatment of the enrollees left lower quadrant abdominal pain, bilateral inguinal hernia, and groin pain. Findings:  The physician reviewer found that chronic postoperative pain is common after inguinal hernia repair. According to data from the Swedish Hernia Registry, 218 out of 167,760 patients underwent reoperation for chronic groin pain. Risk factors for reoperation included young age, female gender, direct hernia, a previous Lichtenstein or plug repair, bilateral repair, and postoperative complications. Colleagues developed an international consensus algorithm for management of chronic postoperative inguinal pain. The authors noted that if an expectative phase of a few months has passed without any amelioration of chronic postoperative inguinal pain, a multidisciplinary approach is indicated and a pain management team should be consulted. Pharmacologic, behavioral, and interventional modalities including nerve blocks are essential. If conservative measures fail and surgery is considered, triple neurectomy, correction for recurrence with or without neurectomy, and meshoma removal if indicated should be performed. Colleagues performed a randomized controlled trial of injection therapy versus neurectomy for postherniorraphy inguinal neuralgia and reported that of the 54 patients randomized, tender point infiltration was successful in 22% while neurectomy was successful in 71%.  The authors concluded that a step up treatment strategy starting with tender point infiltration followed by a tailored neurectomy is advised. This patient has multiple risk factors for chronic postoperative groin pain including young age, previous plug repair, and bilateral repair. Given these recommendations, the patient should proceed with pain management consultation including possible nerve blocks or tender point infiltration prior to any consideration for surgery for neurectomy or mesh removal. Accordingly, the requested surgery to remove and/or repair hernia mesh is not medically necessary. Final Result: The reviewer determined that the requested surgery 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 general 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 magnetic resonance imaging (MRI) of the bone marrow performed for evaluation of his monoclonal gammopathy of undetermined significance (MGUS).  Findings:  Three reviewers found that the whole body MRI is indicated for patients who are being evaluated for smoldering myeloma versus multiple myeloma. MRI can detect diffuse and focal bone marrow lesions in patients with multiple myeloma without osteopenia or focal osteolytic lesions on standard metastatic bone surveys and bone surveys can detect lesions not found on MRI of the axial skeleton. In addition, MRI is supported by the National Comprehensive Cancer Network (NCCN) guidelines. As such, MRI of the bone marrow performed on was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Three reviewers are board certified in internal medicine with sub-specialty certification in hematology and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Rydapt for treatment of the enrollees acute myeloid leukemia. Findings:  The physician reviewer found that there is support in the literature for the requested medication in this clinical setting. Acute myelogenous leukemia is categorized into three risk types: low, intermediate, and high. The stratification is based on cytogenetics. Within this group, clinical outcomes still appear heterogeneous. Therefore, other molecular markers have been identified to enable further prognostication of these sub-types. The patient in this case has a FLT3 TKD mutation. This mutation has been associated with shorter remission durations and decreased overall survival outcomes. The use of Rydapt has demonstrated clinical efficacy and benefit in this AML sub-type. The National Comprehensive Cancer Network guidelines strongly recommend clinical trials as standard therapy for patients with poor prognostic features, which include FLT3 mutations, in the setting of otherwise NK-AML (normal cytogenetics), high white blood cell at diagnosis, or two cycles of induction therapy needed to achieve complete remission. Allogeneic hematopoietic cell transplantation with matched donor is considered standard for those with poor cytogenetics or molecular abnormalities. The submitted documentation indicates that this patient has the molecular characteristics that would make her a candidate for Rydapt, and she meets the U.S. Food and Drug Administration clinical criteria for its use.  For the reasons noted above, Rydapt 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 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 chest computed tomography (CT) scan for evaluation of the enrollees multiple myeloma. Findings:  The physician reviewer found that the presence of an extrapleural mass in this patient with multiple myeloma is of significant concern and the possibility of a neoplastic disorder has to be ruled out. A follow-up CT of the chest is indicated and the CT will serve as a baseline for comparison. The requested CT of the chest will help analyze the adjacent ribs, pleura and lung to assess for any change in size. An increase in size or bone destruction will result in a change in treatment. Moreover, plain film imaging will not provide the same level of detail provided with three-dimensional (3D) CT views. Based upon the records, the requested chest CT scan in this patient is appropriate and medically necessary for evaluation of his multiple myeloma. Final Result: The reviewer determined that the requested service is 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 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: An enrollee has requested authorization and coverage for Ocrevus and Norco (hydrocodone) for treatment of the enrollees multiple sclerosis (MS) and chronic pain. Findings:  The physician reviewer found that the request for Ocrevus is medically necessary for treatment of the patients medical condition. Ocrevus is U.S. Food and Drug Administration (FDA) approved for treatment of MS. Colleagues performed two phase-III randomized clinical trials that demonstrated superiority of ocrelizumab over interferon beta in relapsing-remitting MS (RRMS) patients with regards to clinical and paraclinical outcome parameters. The short-term adverse events profile is favorable. Colleagues found that among patients with relapsing multiple sclerosis, ocrelizumab was associated with lower rates of disease activity and progression than interferon beta-1a over a period of 96 weeks. In addition, although Ocrevus and Rituxan both target CD20-positive B cells, they are different molecules in their structure and how they interact with the immune system. These two drugs bind overlapping but different epitopes on the CD20 molecule. Ocrevus and Rituxan differ in how efficiently they target B-cells. Ocrevus has a higher capacity for direct, antibody-dependent, cell toxicity compared to Rituxan. The records indicate failure of Tecfidera. Given that Ocrevus has shown to be superior to Rituxan as well as being FDA approved for treatment of MS, Ocrevus is medically necessary. The request for (hydrocodone) Norco is not medically necessary for treatment of the patients medical condition. Hydrocodone is an opioid analgesic recommended for pain management when other conservative care has failed. The record notes that the patient has been referred to physical and occupational therapies, however there is no documentation showing the patient has participated in an adequate course of therapy. In addition, opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. The records do not show the patients response to pain medication including the duration of symptomatic relief, functional improvements, and the level of pain relief with Norco. Congruent with the current peer-reviewed guidelines, the requested Norco is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested medications is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the occipital nerve block for treatment of the enrollees intractable migraine headaches. Findings:  2/3 of the physician reviewers found that Occipital nerve blocks are not supported for the treatment of migraine or other type headaches. There was a lack of long-term improvement of headache of chronic migraine type with use of occipital nerve blocks. Greater occipital nerve blocks do not reduce the frequency of moderate to severe migraine days in patients with episodic or chronic migraine compared to placebo. No long-term improvement of headache of chronic migraine type with use of occipital nerve block. For these reasons, the occipital nerve block provided was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the service 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: Physician reviewer number one is board certified in internal medicine and 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.Physician reviewer number two is board certified in internal medicine and 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.Physician reviewer number three is board certified in internal medicine and neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for human growth hormone, Nutropin.Findings: The physician reviewer found that the documentation submitted does not support the medical necessity for the requested medication in this clinical setting. Based on the records submitted, the patient has a normal height that is at the 25th percentile for age and gender. He has a normal growth velocity, normal bone age, and normal growth factors. There are no known morphological abnormalities of the pituitary gland. The patient had a low peak GH level on provocative GH testing. However, this does not support a diagnosis of GH deficiency in the absence of auxological criteria that are consistent with the diagnosis. Provocative GH testing has poor sensitivity and specificity for the diagnosis of GH deficiency, and there is a high false positive rate of such testing in the setting of a low prior probability of disease. For these reasons noted above, human growth hormone, Nutropin is not medically necessary for the treatment of this patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Duavee for treatment of her menopausal symptoms and enlarged uterus. Findings: The physician reviewer has found that based on the submitted clinical notes and current peer reviewed literature, the requested medication is not medically necessary for treatment of this patient.  In this case, the patients chart indicates her menopause complaints were of occasional hot flashes. Menopausal management is a very complex issue. Patients have a variety of physiologic and emotional symptoms related to the change in their hormonal milieu that occurs with cessation of ovarian and or adrenal hormonal production. Management of these symptoms typically needs to be individualized and tailored to help address the specific symptoms the patient may be experiencing and kept in context with any other medical issues they may have. In this patients case, a detailed evaluation of the underlying etiology of her enlarged uterus has not been provided. Additionally, there is no mention of other management modalities that have been trialed by this patient. Specifically, there is no mention of the patient trying other medicinal (hormonal or non-hormonal) and non-medicinal form of therapies. The records do not document the patients response to other medications. While Duavee may help treat hot flashes and other menopausal symptoms, there are other equally reasonable treatment options available to this patient. Duavee may be protective of the endometrium as a SERM, but so are other more traditional progestins. These preparations all carry some risk of endometrial cancer as they are packaged with conjugated estrogens. If the risks associated with estrogens and their potential relationship to uterine or other breast/reproductive cancers is driving management, then the use of non-hormonal management such as Paxil, may be a better option. Duavee has not been found to be safer than other combination options, and has not been approved for the prevention of uterine cancer or other female reproductive tract cancers. For these reasons, the requested medication, Duavee is not medically necessary for the treatment of this patients medical condition. Final Review: 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 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 residential treatment center services provided for treatment of the enrollees behavioral health condition.Findings: The physician reviewer found that based on the Level of Care Utilization System for Psychiatric and Addiction Services (LOCUS) criteria to determine the appropriate levels of care the patient scored 15 meeting criteria for outpatient treatment. The patients risk of harm score is two (2), low risk of harm. The documentation did not show a history of any suicide attempts or suicidal ideation. The patient did have a DUI in which she was under court mandate for treatment. The patients functional status score is two (2), mild impairment. The records showed that the patient had minimal prior treatment. She participated in Alcoholics Anonymous (AA) for seven months. She had some interpersonal problems with her family but was functioning in her self-care and usual activities. Her medical and psychiatric co-morbidity score is two (2), minor co-morbidity. The patient has a co-morbidity of major depressive disorder which was well controlled on Lexapro. She did not have any major medical problems. Her recovery environment score is two (2), mildly stressful environment. The patient has some interpersonal problems with her parents. Her level of support score is two (2), supportive environment. The patients parents are willing to participate in treatment if requested to do so. Her recovery history score is three (3), moderate response to treatment. The patient had limited prior treatment for her alcohol use disorder. She participated in AA for seven months, but this did not lead to complete remission of her alcohol use. Her engagement status score is two (2), positive engagement and recovery. The patient has a positive attitude toward recovery and treatment and is cooperative with staff and treatment recommendations. Based on these criteria, the patient met criteria for outpatient treatment. Therefore, the patient could have been treated in a less restrictive environment during the dates in dispute.Final Result: The reviewer determined that the services at issue were 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CPT code 81420 cell-free DNA testing for evaluation of the enrollees pregnancy. Findings:  The physician reviewer found that The American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine recommended cell-free DNA testing as a screening option for women at increased risk of fetal aneuploidy. This population has been defined as women 35 years or older, fetuses with ultrasonographic findings indicative of an increased risk of aneuploidy, women with a history of trisomy-affected offspring, a parent carrying a balanced Robertsonian translocation with an increased risk of trisomy 13 or trisomy 21, and women with positive first trimester or second trimester screening test results. Since this patient has a normal ultrasound, the aneuploidy risk for this patient in this pregnancy does not warrant cell-free DNA testing for aneuploidy. While a positive association between paternal age and the incidence of aneuploidy has been reported, this is likely due to a close correlation between paternal age and maternal age. Studies that have controlled for maternal age, have not shown an increase in the incidence of trisomy 13, 18 or 21. Testing for genomic sequencing is also not medically indicated due to lack of related family history. All told, the requested CPT code 81420 cell-free DNA testing to be performed is not supported as medically necessary for evaluation of this patients pregnancy. Final Result: The reviewer determined that the requested testing is 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 obstetrics and gynecology with sub-specialty certification in maternal fetal 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.