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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested removal of all facial lesions, moles and spots for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. There is no reason to remove benign skin growths which have been evaluated by a dermatologist, out of concern of future malignancy.  The patient is not considered to be high risk for skin malignancy, as the records do not document a history of organ transplant, immunosuppressive medications, or long-term history of photochemotherapy.  The patients family history of squamous cell carcinoma does not confer enough risk to remove these lesions for prophylactic therapy.  All told, the requested treatment to remove all facial lesions, moles and spots is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 dermatology 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 mechanochemical vein treatment (ClariVein) for treatment of her medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review is insufficient for the treatment proposed. In this case, the patient reports no relief from the use of compression stockings and she reports difficulty walking briskly. It is not possible to attribute the patients symptoms to her varicose veins without an assessment of arterial perfusion to the lower extremities, particularly if compression stockings have no salutary effect. Moreover, there is a lack of large randomized studies demonstrating long term results with ClariVein compared to existing treatments. In sum, there is a lack of support demonstrating that treatment with ClariVein is superior to standard treatment. Final Result: Two 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:  All three reviewers are board certified in vascular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Psychiatrically, her medications were being adjusted. Medically, her vital signs had stabilized.  Although improved, she still required a very high level of prompting.  She continued to subjectively and objectively show a high degree of fear at meals, and to demonstrate eating disorder behaviors.  Her very recent and unstable history between inpatient and residential level of care is concerning and indicates the potential that stepping her down to a lower level of care would quickly lead to decompensation back to a higher level of care.  The structured setting of partial hospitalization level of care initially was medically necessary for this patient to help increase her motivation.  However, subsequently, the patients weight fluctuated; she did not make progress in adding substantive weight over the ensuing period of time, nor was there evidence that she acquired additional substantive skills towards independent eating.  All told, partial hospitalization program services initially provided were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 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 Zometa infusions for treatment of her medical condition.   Findings:  Two physician reviewers found that Zometa infusions were and are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Clinical trials have demonstrated that zoledronic acid added to endocrine therapy improved disease-free survival in premenopausal patients. Postmenopausal women receiving adjuvant letrozole were randomly assigned to immediate zoledronic acid (zoledronate) 4 mg every 6 months for 5 years, or delayed zoledronate (initiated for fracture or on-study bone mineral density (BMD) decrease). The primary end point was the change in lumbar spine BMD at 12 months. Lumbar spine and total hip BMD at subsequent follow-up, disease-free survival (DFS), and overall survival were assessed as secondary end points. Researchers concluded that Immediate zoledronate in postmenopausal women receiving letrozole preserved BMD and is associated with improved DFS compared with letrozole alone. Based on the clinical trial, zoledronic acid improves the disease free survival of breast cancer patients in the adjuvant setting. Furthermore, the Health Plan indicates that the patient has not had treatment failure with an oral bisphosphonate. However, Zometa is not equivalent to oral bisphosphonates. The idea that all the bisphosphonates are equivalent in their efficacy in the adjuvant setting has not been proven. Hence, the use of zoledronic acid in particular is discussed as a therapeutic option in the National Cancer Institutes Physicians Data Query. All told, there is sufficient support in the peer-reviewed literature for the medication at issue in this clinical setting.  Final Result: Two reviewers determined that the medication at issue was and 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 internal medicine with sub-specialty certification in oncology 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:   The parent of an enrollee has requested applied behavioral analysis (ABA) therapy at the frequency of 10 hours per week for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the submitted documentation establishes the medical necessity of the requested therapy. ABA therapy is the standard of care in the therapeutic intervention of autistic children and the documentation submitted for review has confirmed a diagnosis of autism. In sum, this patient has a diagnosis consistent with autism spectrum disorder, for which ABA therapies are medically necessary.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics and pediatric critical care medicine and is actively practicing. Two reviewers are board certified in pediatric 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: 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. The guidelines classify patients with cirrhosis as high priority for treatment.  The guidelines recommend that cirrhotic patients who have failed therapy with Sovaldi and Olysio should be treated with Harvoni and ribavirin for 24 weeks.  The requested medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available modalities.  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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, non-opioid treatment options have not been exhausted. Her currently prescribed non-opioid medications have not all been optimized.  The timeframe for acute pain from the medical condition has ended.  If there is still pain, it would be chronic pain.  The current medical evidence does not support the use of Norco in this clinical setting.  All told, the requested medication Norco is 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 anesthesiology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical evidence, MRI may be an appropriate modality when there is anticipation of some sort of intervention.  This could be surgery, but it could also involve facet injections.  Prior to an intervention, it is reasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  The records demonstrate a normal physical examination, and the referring practitioner also did not feel that an MRI is warranted at this time.  All told, the requested MRI of the lumbar spine 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an inpatient hospital stay for treatment of his status post accident. Findings:  The physician reviewer found that upon review of the submitted documentation, the medical necessity of an inpatient hospital stay has not been established.  Inpatient care is necessary when the patients signs and symptoms and general medical condition can only be managed safely in an acute inpatient setting or when the patient requires diagnostic studies in an inpatient setting. Outpatient observation admission is appropriate when the physician is unsure about the patients need for inpatient admission and requires time for short-term treatment, assessment, and reassessment in order to make that decision or the physician anticipates that the patients condition can be evaluated/treated within 24 hours and/or rapid improvement of the patients condition can be anticipated within 24 hours. In this case, the patient was admitted in stable condition. His vital signs were stable and lab results were unremarkable. He did not require any complex medical treatment or diagnostic studies in an inpatient setting. The submitted clinical documentation does not establish the patient was exhibiting signs and symptoms that could only be managed safely in an acute inpatient setting. All told, an inpatient hospital stay was not medically necessary, as he could have been appropriately treated at an observational level of care. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for the treatment of his medical condition. Findings:  Three physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested services. Proton beam radiation therapy has not been proven to be more beneficial than photon-based intensity modulated radiation therapy in this clinical setting.  There is a lack of published trials with clinical endpoints comparing proton beam therapy and photon-based intensity modulated radiation therapy for oropharyngeal carcinomas.  Clinical studies comparing proton beam radiation therapy and photon-based intensity modulated radiation for paranasal carcinomas and skull base tumors are not clinically translatable to oropharyngeal carcinomas, as treatment volumes are usually different.  All told, proton beam radiation therapy is not likely to be superior over other treatment options.Final Result: 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: Reviewers 1, 2, and 3 are board certified in radiation oncology 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 hydrocodone 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 non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In a retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose and short-acting opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, hydrocodone is 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 anesthesiology 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 the takedown of Rouxen-Y gastric bypass and conversion to a duodenal switch for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records do not document any overt complication of the prior open gastric bypass.  It is unclear that this patient would be compliant with a revisional type procedure to offset the increased risk of complications of revisional surgery.  All told, the requested takedown of Roux-en-Y gastric bypass and conversion to a duodenal switch is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of her 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 guidelines, treatment-naive, genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage.  For these reasons, Sovaldi for is medically indicated for the treatment of this patient.  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.