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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of her medical condition. Findings: Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Rituxan is an appropriate treatment option for relapsing multiple sclerosis patients who have not tolerated or had suboptimal therapeutic response to standard multiple sclerosis therapies. Rituxan also may be considered a reasonable treatment option in patients with rapidly progressive multiple sclerosis. Data support that Rituxan therapy in the treatment of secondary progressive multiple sclerosis could stabilize, and potentially reverse, the rate of disease progression.  In this patients case, Rituxan is likely to be superior over other treatment options.  Final Result: Three reviewers determined that the requested medication is 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:   All three reviewers are board certified in neurology and are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with the two dimensional technique alone.  Final Result: Three 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 reviewers are board certified in diagnostic radiology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to 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 applies regardless of fibrosis stage or viral load. Per the guidelines, genotype 1a patients who have failed PEG-interferon/ribavirin should be treated with Harvoni for 12 weeks. These guideline 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 (Afdhal, et al). The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to prior anemia with ribavirin  anemia can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested insertion of an artificial intervertebral disc for treatment of his medical condition.  Findings:  Two physician reviewers found that the peer-reviewed literature supports the use of artificial disc replacement in the setting of single level cervical degenerative disc disease when clinical indications are met as documented in this case. The patient presents with intractable single level cervical degenerative disc disease confirmed by imaging. Clinical exam findings document motor deficit and positive neurocompressive signs consistent with imaging. Detailed evidence of recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted. Moreover, the use of cervical disc arthroplasty will likely allow for motion preservation in this young patient. Therefore, the insertion of an artificial intervertebral disc was likely to be more beneficial for treatment of the enrollees medical condition than any available standard treatment.   Final Result: Two reviewers determined that the services at issue were 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:  All three reviewers are board certified in orthopedic surgery and are 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cryoablation for treatment of her medical condition.   Findings:  Two physician reviewers found that several multi-institutional trials have demonstrated cryoablation to be a successful option for the resolution of fibroadenomas without surgical excision. The U.S. Food and Drug Administration (FDA) has approved the use of cryoablation as a safe and effective therapy for fibroadenomas. Results of cryoablation have been followed out to four years and demonstrate the procedure to be safe, efficacious, and durable.  Cryoablation offers an alternative to surgical excision of benign fibroadenomas.  Due to the analgesic effect of cold temperatures, the procedure is virtually painless to the awake patient, and can be performed safely in the office with no sutures and little to no scarring.  All told, the requested cryoablation is likely to be superior over other treatment options.  Final Result: Two reviewers determined that the requested services are 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:  One reviewer is board certified in obstetrics and gynecology and is actively practicing   Two reviewers are board certified in surgery and are 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: An enrollee has requested  loperamide for treatment of her medical condition. Findings: The physician reviewer found that loperamide hydrochloride capsules are indicated for the control and symptomatic relief of acute nonspecific diarrhea and of chronic diarrhea associated with inflammatory bowel disease. Loperamide hydrochloride capsules are also indicated for reducing the volume of discharge from ileostomies. However,  U.S. Food and Drug Administration (FDA) guidance suggests dosing for these indications is appropriate at considerably lower milligrams than this patient routinely consumes. Toxicity is case-reported to include dependency, respiratory depression, catatonia, and the drug has the potential for euphoric effects that in some cases have required administration of naloxone or referral for drug rehabilitation.  In this case, the patients daily loperamide requirements are outside of the norm, and the requested doses are not standard of care. Moreover, it is unclear from the provided records that the patient has exhausted all conventional medications in treatment of the underlying cause of her diarrhea for which ostensibly loperamide has been required. Given the above, the support for the requested medication is not medically necessary for 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 physician 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 Harvoni for treatment of his 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the current guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni is 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.   Findings:  Three physician reviewers found that current guidelines do not recommend routine use of advanced lipoprotein tests, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. A lipoprotein measure obtained from an advanced test is clinically useful if the following criteria are met: it adds to clinical knowledge; it provides risk information that is independent of established predictors; it is easy to measure and interpret in a clinical setting; it is accurate, reproducible, and internationally standardized; and it has a favorable cost-benefit ratio. Importantly, the lipoprotein measures should improve patient management, particularly through more accurate risk classification and guiding choice of therapy (Mora, et al). In this case, the patients previous fasting lipid studies showed low-density lipoprotein (LDL) and normal high-density lipoprotein (HDL) necessitating no change in statin therapy. Thus, the patient already had well controlled lipid levels and the results would not have altered therapy. All told, the advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are 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:   An enrollee has requested anesthesia services for treatment of his medical condition.   Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with propofol. McQuaid and Laine performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. The authors concluded that moderate sedation provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. Midazolam-based regimens have longer sedation and recovery times than propofol. In this case, the anesthesia services were not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. Moreover, the standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and co-morbid conditions that would put the patient at risk during the procedure. There is no documentation of co-morbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care. Given the above, 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  MRI of the breast has specific indications as outlined by the American College of Radiology.  The most common indications for breast MRI is for high-risk women or for evaluation of a newly diagnosed cancer to rule out multifocal or multicentric disease.  MRI is a very sensitive exam in the diagnosis of breast cancer, but has a low specificity.  It is rare to diagnose a breast cancer in the setting of a negative clinical exam, negative mammography, and negative sonography.  Based on risk factors, this patient does not meet the requirements for MRI screening.  All told, the requested MRI of the breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested whole exome sequencing (WES) genetic testing for evaluation of the enrollees medical condition.   Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. WES is a newly available technology whereby the portion of the genome consisting of coding sequences is analyzed to look for variants that may explain the patients phenotype. Clinical indications for WES are a suspected genetic disorder based on signs and symptoms, with no known single gene condition fitting the phenotype. The utility of WES for gene discovery (to identify the genetic cause of well-characterized specific phenotypes) has been demonstrated.  Information about the utility of WES in the clinical arena, when applied to an individual patient, is emerging. Studies that have examined whether the results have changed medical management indicate that management is altered in approximately 10% of cases. In addition, there are preliminary data showing that the incidence of actionable incidental findings (those unrelated to the indication for testing) is approximately 3% in certain patient populations (Yang, et al). Given the accumulating data supporting the clinical utility of WES, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard 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: One reviewer is board certified in pediatrics and clinical genetics and is actively practicing.  Two reviewers are board certified in pediatrics and are 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:   An enrollee has requested Repatha injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has increased coronary risk but no documentation of coronary stenosis or clinical coronary event, such as angina or myocardial infarction.  There is no documentation to support a history of homozygous familial hypercholesterolemia or heterozygous hypercholesterolemia.  Familial hypercholesterolemia usually manifests by a combination of physical exam findings and low-density lipoprotein levels that are at minimum above 180, and usually significantly higher.  This is not documented in the medical records provided.  Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical heart disease who require additional lowering of low-density lipoprotein cholesterol.  This patient does not fit any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this clinical setting.  The current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications that have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. Therefore, the requested Repatha injections are not medically indicated for the treatment of this patient.   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 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.