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 Vemlidy 25 mg tablets. 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 (Viread and Vemlidy) compared to the alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient takes, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with fewer side effects, including decreased risk of osteopenia and renal disease. 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursemtnt for emergency medical services.Findings:  The physician reviewer found that The medical services provided were necessary for treatment of an emergency medical condition. In this case, the patient sustained a left distal femur fracture in a 15-foot fall and underwent intramedullary nailing. One of the distal locking screws began to loosen and back out through the skin. He presented to the emergency room for immediate removal due to the infection risk. Hardware removal was performed under local anesthesia. He was prescribed IV antibiotic prophylaxis. The patient was subsequently discharged on  after pain was controlled on oral medications, the patient was able to void and pass stool, and the patient was able to ambulate with a front-wheeled walker. The services provided were necessary for an emergent basis to address the hardware complication and avoid the significant infection risk that posed to this patient. Therefore, the hospital stay provided is considered emergency medical services. Thus, the patient did receive emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient received emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing for evaluation of the enrollees colon cancer.  Findings:  Two physician reviewers found that the FoundationOne gene testing provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, at the time FoundationOne testing was performed the patient presented with newly diagnosed with metastatic colon cancer. It has not been established if molecular markers are useful in treatment determination and prognosis in patients with colon cancer, especially prior to first-line therapy. Routine molecular profiling is not considered a standard of care and is not endorsed by the National Comprehensive Cancer Network (NCCN) guidelines. Molecular profiling for solid tumors is the ongoing subject of several active clinical trials. Final Result: The 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Radicava for treatment of the enrollees amyotrophic lateral sclerosis (ALS). Findings:  The physician reviewer found that in May 2017, Radicava was approved by the U.S. Food and Drug Administration (FDA) to treat patients with ALS. Radicava showed efficacy in a small subset of patients with ALS who met criteria identified in post-hoc analysis of a previous phase 3 study, showing a significantly smaller decline of ALSFRS-R score compared with placebo. Currently, there are no other therapies available similar to this medication for the treatment of ALS. Accordingly, the requested Radicava is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in neurology 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 blepharoplasty and reconstructive repair of ptosis for treatment of the enrollees bilateral eyelid ptosis and are not reconstructive in nature. Findings:  The physician reviewer found that in this patients case, the requested services are medically necessary and are reconstructive in nature. Multiple publications have confirmed the functional significance of even mild blepharoptosis. According to the American Academy of Ophthalmology (AAO), blepharoplasty procedures and repair of blepharoptosis are considered functional and reconstructive in nature when certain criteria are met. This patients photographs show that the upper eyelid skin rests on the lashes, and the visual fields demonstrate a 30-degree loss of the upper field of vision that corrects with taping. Marginal reflex distance measurements are less than 2.5 mm based on the submitted record. As such, the AAO guidelines are met.  The visual field tests confirm the presence of functionally significant visual field loss, and the photographs are consistent with the perimetry results. According to the medical literature, dermatochalasis is known to cause visual field defects in many patients. Patients often report that their vision is brighter following upper eyelid blepharoplasty. Cahill and colleagues report the following, Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities.  The submitted records support that this patient has functionally significant upper lid dermatochalasis with visual field losses. This condition is an abnormal structure of the body that affects this patients vision. As such, the requested surgeries will improve function as well as provide more than a minimal improvement in appearance. All told, repair of blepharoptosis will provide improvement in this patients vision and quality of life activities. Final Result: The reviewer determined that the requested services are medically necessary for treatment of this patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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 occipital nerve block injections for treatment of the enrollees occipital neuralgia. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting. This patients pain complaints are corroborated by physical examination and medical history. In particular, there is objective documentation of occipital neuralgia to substantiate the need for occipital nerve blocks. In addition, the patients occipital neuralgia has been unresponsive to conservative measures, including neuropathic pain medications and muscle relaxants. The medical evidence supports occipital nerve block injections in this case. Therefore, occipital nerve block injections were likely to have been of greater benefit than other treatment options. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for occupational therapy services from an occupational therapist located within approximately 5 miles or 10 minutes from his residence for treatment of the enrollees gross motor delays. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. This patient has deficits in many areas of functioning, including, but not limited to, fine motor skills, motor planning skills, coordination and balance, visual motor integration, speech and language skills, postural stability, and performance of age-appropriate self-help skills. His care is managed by pediatric neurology, but he does not yet carry a unifying diagnosis. He has been receiving occupational therapy in a facility close to home, with documented progress and a well-established relationship with the therapist. However, he has not yet achieved age-appropriate functional skills, and ongoing therapy has been recommended. Based on the current standard of care, ongoing occupational therapy services are medically necessary and appropriate. Provision of such services should be achieved in the least restrictive environment to allow the child to participate fully and benefit maximally. With an established relationship in a facility close to home, this child has the best opportunity to flourish. Occupational therapy services at the closest facility with which the child and family have a relationship are thus medically necessary and appropriate. 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 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: An enrollee has requested authorization and coverage for biofeedback training, perineal muscle, anorectal or urethral sphincter for treatment of the enrollees pelvic floor dysfunction. Findings:  The physician reviewer found that found there are a number of causes for obstructed defecation syndrome and pelvic floor dysfunction, including rectocele, rectal intussusception, paradoxical muscular contraction, descending perineum syndrome, sigmoidoceles, or enteroceles. Some of these are structural anatomical issues, but others are functional issues with normal anatomy. If functional abnormalities are present, lifestyle modification and biofeedback therapy can be effective. The American College of Gastroenterology guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, is also warranted when evacuation or outlet disorder is suspected. These have been performed. The medical evidence supports the requested services in this patients case. 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 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 authorization and coverage for Epclusa for 12 weeks. 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 life expectancy less than 12 months due to non-liver-related conditions. This applies in all cases, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. The medical evidence supports the requested medication regimen in this clinical setting. All told, Epclusa for 12 weeks is medically necessary for the treatment of this patient. 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: The patient has requested authorization and coverage for oxycodone ER 20 mg for treatment of the enrollees incomplete cervical spinal cord injury (SCI) due to trauma. Findings:  The physician reviewer found that The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Applying this guideline, not all non-opioid and narcotic treatment options have been utilized in this patients case. There is no documentation of the completion of behavior therapy despite much research to support its use. Furthermore, no objective treatment goals for pain and function are noted for the requested medications. The Centers for Disease Control and Prevention (CDC) also state that when opioids are started, providers should prescribe the lowest effective dosage. Finally, not all non-opioid and non-narcotic medications classes have been optimized or tried. 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: The patient has requested authorization and coverage for upright/standing magnetic resonance imaging (MRI) scan with contrast for evaluation of the enrollees lung cancer. Findings:  The physician reviewer found that the patients desire to avoid ionizing radiation is reasonable if there are adequate alternatives that do not require radiation for completion. The patients concern of coughing, claustrophobia and headache require accommodation if possible. In a patient with such physical limitations, open MRI is an alternative especially if the studies are broken up into three different examinations which will minimize the extended time in the magnet. The open nature of the magnet will alleviate the feeling of claustrophobia and the time spent for each of the three studies will be relatively short. However, the records provided do not support the medical necessity for an upright MRI study in this patients case. Moreover, there is a lack of medical literature demonstrating that an upright MRI would be indicated in lieu of standard imaging. Thus, the requested upright/standing MRI scan with contrast is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: The patient has requested authorization and coverage for Xeljanz (XR tablet ER 24h) for treatment of the enrollees rheumatoid arthritis. Findings:  The physician reviewer found that the available medical records do not document a trial and failure of Enbrel and Humira. A fear of needles is not considered a contraindication for treatment with Enbrel or Humira. Moreover, the medical literature supports the clinical efficacy and safety of treatment with Enbrel and Humira in the treatment of rheumatoid arthritis. On the basis of this lack of documentation, the requested Xeljanz (XR tablet ER 24h) is not indicated as 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 reviewer is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50-100 mg 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. The guidelines recommend that genotype 1a patients who have failed PEG-interferon and ribavirin should be treated with regimens including 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50-100 mg for 12 weeks 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the chiropractic services for treatment of the enrollees migraines. Findings:  The physician reviewer found that as noted in the medical literature, chiropractic care has an effect comparable to commonly used first-line prophylactic prescription medications for tension type headache and migraine headaches. Additional data suggests that chiropractic effect on headaches is inconclusive. As this patient is already taking a first-line prophylactic medication, further treatment with chiropractic manipulation was not medically necessary. All told, the chiropractic services provided 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 chiropractic 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.