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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcranial magnetic stimulation (TMS). Findings:  The physician reviewer found that TMS is a specific treatment for severe depression and is U.S. Food and Drug Administration (FDA) approved. The patient has been treated with psychopharmacology and psychotherapy, and he has received adequate trials in terms of dosage and duration of treatment with two FDA approved selective serotonin reuptake inhibitors (SSRI) mediations, Prozac and Lexapro, as well as Wellbutrin and Pristiq, which have different mechanisms. He has also been augmented with stimulants, atypical antipsychotics, mood stabilizers and a folate analogue, all without benefit. He has been engaged in CBT psychotherapy weekly for more than six months. In this case, the patient has been treated with the standard of care treatments for depression without much improvement. In sum, the patient has treatment resistant depression and treatment with TMS is clinically indicated. For the reasons provided, the request for TMS has been established as medically necessary for treatment of the patients major depressive disorder. 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for ThyGenX oncogene testing. Findings:  The physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Genetic testing on thyroid nodules is generally considered standard protocol on fine needle aspirations done on thyroid nodules.  There is sufficient literature to indicate that this test can help avoid unnecessary surgeries.  In this patients case, the initial biopsy came back as indeterminate. ThyGenX oncogene testing was positive and helped to lead to definitive surgical management. In sum, ThyGenX oncogene testing performed was likely to have been superior over other methods of evaluating this patient. Final Result: 3 of 3 reviewers determined that the services at issue were 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: All three physician reviewers are board certified 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 Trulicity 0.75 ng.0.5 pen injector. Findings:  The physician reviewer found that the American Diabetes Association (ADA) support the additional of a second oral agent, a glucagon-like peptide 1 receptor agonist, or basal insulin if noninsulin monotherapy at maximum tolerated dose does not achieve or maintain the A1C target after three months. Trulicity is a glucagon-like peptide 1 (GLP-1) receptor agonist (GLP-1RA). It is one of the noninsulin agents in the algorithm for the pharmacological treatment of diabetes. The combination of insulin plus a GLP-1RA has been used for a long time to address the metabolic defects of diabetes. Many studies document the efficacy of the combination of basal insulin plus a GLP-1RA for use in this clinical setting. Studies noted that GLP-1 analog and basal insulin combination treatment can enable achievement of the ideal trifecta in diabetic treatment: robust glycaemic control with no increased hypoglycaemia or weight gain. This combination is thus a potential therapeutic strategy that could improve the management of patients with type 2 diabetes. This patient has been trying to control her diabetes for many years. The patient has a documented contraindication to metformin with reported an adverse effects. Experts in diabetes management know that pioglitazone and insulin are responsible for weight gain, which was the case here, and fluid retention. Sulfonylureas are not very effective in a patient already on short acting insulin and can cause hypoglycemia. The addition of Trulicity to the basal insulin regimen is the best choice for this patient that has uncontrolled diabetes, obesity, and risk of hypoglycemia. Thus, the Trulicity 0.75 mg/0.5 pen injector to the current regimen is medically necessary for the treatment of this patients diabetes. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for gene testing. Findings:  The physician reviewers found that the European Association Urology (EAU) guidelines on prostate cancer indicates that the Prolaris test has been shown in prospective studies to provide prognostic information in men with clinically localized prostate cancer, additional to conventional clinico-pathological parameters, including Gleason score and PSA level. The EAU concluded that The results of prospective multicentre studies are awaited before a recommendation can be made regarding their routine application. The National Comprehensive Cancer Network (NCCN) guidelines for prostate cancer recommend the use of Prolaris in the post-biopsy period for very low and low risk prostate cancer. Based on the available information, the patient does not have very low risk or low risk prostate cancer. The patient has intermediate risk prostate cancer and the use of Prolaris testing would not have altered the course of management. Therefore, the gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2 of 3 reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in urology 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: An enrollee has requested reimbursement and prospective authorization and coverage for licensed vocational nurse (LVN) skilled nursing home care services for 56 hours per week from the date of service in question, forward. Findings:  The physician reviewer found that spastic cerebral palsy is the most common form of cerebral palsy, representing at least 70% of diagnoses. Cerebral palsy is a group of disorders primarily affecting muscle coordination, balance and voluntary movement. The neurological condition typically appears in infancy or early childhood, resulting from irregular development or damage to the part of the brain responsible for mobility. Among patients afflicted with the spastic type of cerebral palsy, muscle tightness and poor coordination during deliberate movements are consistent, dominant symptoms. As with other forms of cerebral palsy, patients with the spastic type are susceptible to co-occurring conditions, which can impact vision, hearing, swallowing, as well as bladder and bowel functions and other physical systems. Spastic diplegia is a form of cerebral palsy that affects the lower portion of the body. According to the studies published by the National Center for Biotechnology Information, patients with spastic diplegia may see many of the other developmental conditions as those with quadriplegia, including vision problems. Skilled nursing care consists of those services that must be performed by a registered nurse (RN) or LVN. Skilled home health nursing care is the provision of intermittent skilled services to a patient within the home for the purpose of restoring and maintaining the patients maximal level of function and health. These services are rendered in lieu of hospitalization, confinement in an extended care facility, or going outside of the home for the service. The records provided for review support the medical necessity of the requested LVN skilled nursing home care services for 56 hours per week from the date of service, forward for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 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 parent of an enrollee has requested authorization and coverage for 33 hours per week of direct applied behavioral analysis (ABA) therapy, 13 hours per month of supervision and four hours per month of parent training for treatment of the enrollees autism. Findings: The physician reviewer found that one article studied 726 autistic children, ages 1.5 to 12 years, who were found to make increased progress towards learning objectives with increased intensity of ABA treatment. The Health Plan has authorized 16 hours per week of direct ABA and six hours per month of oversight. Several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Per the most recent progress report, the patient continues to demonstrate significant delays in vocal stereotypy, outburst behaviors and non-compliant behaviors. Failure to master these skills puts the patient at an increased risk for injury. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: Anenrollee has requested authorization and coverage for Zepatier 50-100 mg tablets for 12 weeks. 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. This recommendation applies to all patients, regardless of fibrosis stage. Additionally, this patient has joint pain with positive cryoglobulinemia testing and patients with symptomatic extrahepatic manifestations are prioritized for treatment per the AASLD/IDSA guidelines. In addition, the guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent . The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment . All told, the requested treatment with Zepatier 50-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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 Epclusa 400-100 mg tablets for 12 weeks. 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 do not comment on the treatment of genotype 6 hepatitis C after failure of a direct-acting antiviral agent but reference re-treatment after peg-interferon and ribavirin failures only. The guidelines recommend 24 weeks of Epclusa and the use of ribavirin in patients with genotypes 1 or 3 who have failed an nonstructural protein 5A (NS5A) inhibitor such as Harvoni or Daklinza, based on clinical trial data. Additionally, guidelines issued by the European Association for the Study of the Liver (EASL) state that after failure of an NS5A inhibitor, such as Harvoni, re-treatment of genotype 6 patients should be performed with Epclusa and ribavirin for 24 weeks, which is not the regimen requested in this case. The ASTRAL-1 trial does not lend support to the requested treatment, as it did not include any genotype 6 patients who failed an NS5A inhibitor and then were re-treated with Epclusa . For these reasons, the requested treatment with Epclusa to be used with ribavirin for 12 weeks is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. 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 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 reimbursement for Oncotype DX Prostate Cancer Assay for evaluation of the enrollees prostate cancer. Findings: Two of the three physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision-making in newly diagnosed men considering active surveillance and in treated men considering adjuvant therapy or treatment for recurrence. Men with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network risk groups. These include, but are not limited to, likelihood of biochemical progression after radical prostatectomy or external beam therapy, and likelihood of developing metastasis after radical prostatectomy or salvage radiotherapy.  The medical evidence supports the services at issue in this clinical setting. Final Result: The reviewers determined that the services at issue were 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar spinal fusion. Findings:  The physician reviewer found that  Evidence based medical guidelines support lumbar spine fusion for isthmic or degenerative spondylolisthesis with instability, and/or symptomatic radiculopathy, and/or symptomatic spinal stenosis. Wang and colleagues noted that lumbar fusion may be appropriate for patients with degenerative disc disease and disc herniations with radiculopathy when a herniation is associated with evidence of spinal instability, chronic low-back pain, and/or severe degenerative changes, or if the patient participates in heavy manual labor. A study concluded that patients presenting with stenosis associated with a spondylolisthesis will often describe signs and symptoms consistent with neurogenic claudication, radiculopathy, and/or low back pain. The primary objective of surgery, when deemed appropriate, is to decompress the neural elements. As a result of the decompression, the instability associated with the spondylolisthesis may progress and lead to further misalignment that results in pain or recurrence of neurological complaints. Under these circumstances, lumbar fusion is indicated to stabilize the spine and prevent delayed deterioration. Lumbar fusion is also supported in the setting of wide decompression with anticipated intraoperative instability. This patient presents with persistent worsening low back pain radiating into both lower extremities in an L5 distribution, worse on the right. Significant functional difficulty is documented in his ability to perform activities of daily living. In addition, the patients signs and symptoms are consistent with imaging evidence of spondylolisthesis at L5-S1 with foraminal stenosis and nerve root compromise. Moreover, there is electrodiagnostic evidence of chronic L5-S1 radiculopathies and radiographic evidence of spondylolisthesis at L5-S1 with instability documented on flexion/extension views. The provider noted the need for wide decompression to achieve adequate nerve root decompression which would result in intraoperative instability and necessitate fusion. For these reasons, the requested lumbar spinal fusion is considered medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary  An enrollee has requested authorization and coverage for Prolastin-C infusion augmentation therapy. Findings:  The physician reviewer found that: The use Prolastin-C infusion in this patient is not consistent with the U.S. Food and Drug Administration (FDA) approved indications. The records indicate this patient has been treated with Prolastin-C infusion for augmentation treatment for alpha-1 antitrypsin deficiency. However, the approved indications include patients who are homozygous and have an alpha-1 antitrypsin level less than 11. This patient is heterozygous, has an alpha-1 antitrypsin level of 57.4, and the phenotype is MZ. There is no objective documentation that the use of augmentation therapy for patients who are heterozygous improves the long-term health outcomes. All told, the requested Prolastin-C augmentation therapy in this patient is not medically necessary.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 pulmonary 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