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

Nature of Statutory Criteria/Case Summary: A 55-year-old female enrollee has requested authorization and coverage for the LINX reflux management system for treatment of the enrollees gastroesophageal reflux disease.Findings:  The physician reviewer found that There is a lack of randomized controlled trials with long-term follow-up demonstrating that LINX is safer or more effective than Nissen fundoplication or other surgical anti-reflux procedures. Adverse events, such as erosion through the esophagus, have been reported in the period after U.S. Food and Drug Administration (FDA) approval. Additionally, LINX (more than surgical fundoplication) is associated with severe dysphagia requiring endoscopic intervention. The currently available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial in this case than standard treatment, surgical fundoplication. American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended. Thus, the LINX reflux management system is not likely to be more efficacious than other available treatment options. Final Result: Two of three reviewers determined that the requested services are 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 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.Physician reviewer number two 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.Physician reviewer number three 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 reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. The patient was at moderate risk of harm (score 3) with chronic passive suicidal ideation. The patient did not have any active suicidal ideation with a plan. She has a history of non-suicidal self-injury, but from documentation, by  the patient was not inflicting self-harm. The patient was noted to demonstrate moderate functional impairment (score 3) given her history of appearance and hygiene deficits, which had improved with treatment. She has a significant deterioration in her ability to fulfill her responsibilities of school work. She has ongoing interpersonal relationship problems with her parents and does not like to be at home. The patient demonstrates significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, and unspecified eating disorder. The patients recovery environment is moderately stressful (score 3) and her environmental support is limited (score 3) as the patient has supportive parents but does not seem to utilize these sources of support. The patient has shown equivocal resiliency and response to treatment (score 3) as previous treatment did not achieve complete remission and partial recovery has been maintained for moderate periods of time with strong professional support in structured settings. The patient has been obstructive to treatment (score 3) as she has difficulty establishing positive relationships with providers, she has limited insight in her condition, and resists accepting responsibility for development and consequences of her problems. This composite score of 21 is consistent with treatment at the partial hospitalization program (PHP) level of care. The patient did not have any medical problems which required 24-hour supervision. The patient continued to require care for her mental health problems, but this could have been done in a less restrictive environment. 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 child and adolescent 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 reimbursement for air ambulance transportation services for treatment of the enrollees Ehlers-Danlos syndrome with positional paralytic apnea. Findings:  The physician reviewer found that the air ambulance transportation services were not medically necessary for treatment of the patients medical condition. There is a lack of documentation demonstrating that the original surgeon was clinically indicated for revision surgery. There are multiple providers closer to the patient that would have been adequate and capable of providing the surgical procedures provided. The proposed surgery could have been provided by any fellowship trained orthopedic spinal surgeon or neurosurgeon with a specialization in spinal surgery.  As such, the services at issue were not medically necessary for treatment of the patients medical condition. 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 neurological 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 Foundation One gene panel testing for evaluation of the enrollees recurrent papillary thyroid carcinoma. Findings:  Two physician reviewers found that Papillary thyroid cancer is a frequent histologic subtype of thyroid cancer and data suggests that BRAF mutations are frequent. This is notable since the presence of the mutation provides significant prognostic information and potential targeted therapies. The authors reported that the regimen selected by molecular profiling offered a 27% survival advantage. This patients tumor tested positive for BRAF mutation and PIK3CA, which supports consideration of kinase inhibitor therapy. Final Result: Two reviewers determined that the testing 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: All three reviewers 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 Harvoni 90-400 mg, one tablet per day, for 12 weeks for treatment of the enrollees hepatitis C. 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. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Jakafi 10 mg for treatment of myelogenous leukemia status post hematopoietic stem cell transplant (HSCT) presenting with graft versus host disease (GVHD). Findings:  The physician reviewer found that the U.S. Food and Drug Administration (FDA) granted a breakthrough therapy designation to Jakafi for the treatment of patients with acute GVHD in June 2016 based on promising preliminary results from two published studies. However, this patient has chronic, not acute, GVHD. Thus, the use of Jakafi is not supported by the current available medical literature. The standard treatment for chronic GVHD is summarized in the literature. Most recently, ibrutinib was FDA approved for the treatment of chronic GVHD providing a 67% response rate. 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 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: A female enrollee has requested authorization and coverage for a partial liver lobectomy at a tertiary care center for the treatment of the enrollees hepatic cyst. Findings:  The physician reviewer found that The submitted documentation supports the medical necessity of the services at issue. This patient requires an expert, hepatobiliary-trained surgeon.  Her tumor is a rare tumor, and complete surgical resection is appropriate. Her case is complicated by previous unroofing. Hopefully, this will not be an issue but does create scarring/adhesions which make subsequent resection difficult. Additionally, although the pathology appears benign, what was left behind may not be.  In this patients case, the anatomy makes the surgery challenging.  Her provider has noted that the patient may need portal vein embolization.  Per the records, the patient has a central lesion which will likely require extended resection.  This may be an intraoperative decision based on the ability to preserve blood supply and parenchyma.  Trisegmentectomies are very high-risk procedures, and the hospital support structure must be set up to handle all aspects of her care. The current medical evidence supports the requested services in this patients case. All told, the requested partial liver lobectomy at a tertiary care center is medically necessary for the treatment of this patient. 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 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 carisoprodol (Soma) 100 tablets per 30 days for treatment of the enrollees chronic cervical and lower back pain.Findings:  The physician reviewer found that Based on the documentation submitted for review, the medical necessity for the requested medication has not been established. Current standard of care for chronic pain and spasms is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Additionally, the medical literature indicates that Soma is a muscle relaxant with more addictive and abusive properties than opioids. Soma is a centrally acting muscle relaxant, associated with a high risk of dependence and tolerance. Long term administration is not recommended. Baron and colleagues reported that high dose opiates and centrally acting muscle relaxants might contribute to sensitization via hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of opioids and other medications such as Soma for a chronic medical condition reported a significant decrease in pain at the end of the study, further supporting the theory of hyperalgesia.  Ballantyne and colleagues also reported that prolonged use of centrally acting medications might induce tolerance and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of medication therapy. In this patients case, prescribing Soma would be contradictory to providing safe and effective treatment. As such, the carisoprodol (Soma) 100 tablets per 30 days 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 anesthesiology with sub-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 advanced lipoprotein testing. Findings: Two reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein testing. According to the ACC, there is a lack of data to indicate a benefit for advanced lipoprotein testing over the basic lipid profile. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy.Final Result: Two reviewers found that testing 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 reviewers 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 requested reimbursement for occipital nerve blocks for treatment of the enrollees chronic migraines. Findings:  The physician reviewers found that the efficacy of greater occipital nerve blocks in the management of chronic migraine remains uncertain. There are conflicting data concerning treatment response for this procedure. At this time, it is not considered to be an accepted standard of care or treatment. Prophylactic/preventative medications for migraine remain more appropriate treatments. Therefore, occipital nerve blocks were not likely to have been more beneficial than standard therapy in this patients case. Final Result: Two of three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in neurology and 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 Vemlidy for treatment of the enrollees hepatitis B. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease.  This would apply whether or not there has been e antigen seroconversion or detectable virus, as most patients require chronic therapy given the risk of relapse when therapy is discontinued. There are no clear recommendations to stop therapy even if e antigen seroconversion is achieved. For this reason, the request for Vemlidy is medically necessary for the treatment of this patients chronic hepatitis B. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic testing for evaluation of the enrollees major depressive disorder. Findings: Three physician reviewers found that the documentation provided does not indicate that the patient has failed medication trials of adequate dose and duration or that the patient has tried or failed evidence based psychotherapy trials. In addition, there is no documentation that the patient has been treated with psychotherapy. The literature supports outpatient treatment as well as family therapy in managing suicidal ideation and behaviors for adolescents. Moreover, the current literature indicates that effective self-harm reduction can occur with therapy available on an outpatient basis such as dialectical behavioral therapy. The current evidence indicates that the patient could benefit from psychotherapy for her behavioral health condition. The evidence base does not support the use of pharmacogenomic testing in this clinical setting. One study noted that there is still considerable controversy on whether adjustment of dosage driven by genetic information may improve therapeutic efficacy, and/or adverse events is prevented, to an extent of any practical importance in clinical practice. Another study reported that routine application of pharmacogenetic dose adjustment in clinical practice requires prospective validation. Final Result: Three physician 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 psychiatry with sub-specialty certification in child and adolescent psychiatry 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.