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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior lumbar interbody fusion L5-S1 for treatment of her L5-S1 degenerative disc disease. The physician reviewer found that review of the submitted documentation does not establish the medical necessity of anterior lumbar interbody fusion L5-S1. Flexion extension films have not demonstrated instability. In addition, there is limited localization of structural changes at L5-S1 as opposed to a more generalized pain generation at more proximal levels as well as L5-S1. The anatomical studies do not emphasize spinal stenosis, either central spinal stenosis or neural foraminal stenosis. As discussed in the medical literature, chronic regional pain treated with single level focal surgical procedures is not likely to be efficacious because of the multifactorial nature of chronic lumbosacral pain. There are also substantial risk factors associated with an anterior approach which expose the patient to potential injury to iliac veins and ureter. The literature does not demonstrate that the requested anterior lumbar interbody fusion L5-S1 will result in a better outcome in the setting of chronic regional lumbosacral pain syndrome than continued conservative care. Accordingly, the requested service is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested speech therapy for treatment of the enrollees speech delay.  The physician reviewer found that according to the literature, speech and language deficits that persist into the primary school years have long-term effects on literacy, socialization, and behavior.  In particular, speech sound disorder not only greatly reduces intelligibility, but has also been associated with later reading disability.  Speech sound disorders refer to any combination of difficulties that impact speech intelligibility, including perception, motor production, and phonological representation of speech sounds and segments.  Articulation disorders are those that impact the form of speech sounds and are associated with structural and motor-based problems. Phonology disorders impact the way speech sounds function within a language.  The treatment approaches have traditionally focused on either articulation or phonology.  The literature supports speech therapy intervention in this clinical setting.  This patient has made significant progress with intervention, but has not yet achieved age appropriate articulation skills.  All told, speech therapy is medically indicated for the treatment of this patient. 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 with sub-specialty certification in pediatric critical care 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 Subsys for treatment of her chronic pain.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Subsys has not been established. Subsys is not medically necessary in this clinical setting. The current standard of care for chronic pain associated with lower back pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy.  Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced 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 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. For the reasons provided, the patients request for Subsys is not medically necessary.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 sacroiliac joint fusion of the left side for treatment of her left sacroiliac joint pain.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. SI joint fusion is not the standard of care for SI joint disorders. In addition, the medical records submitted for review do not demonstrate that this patient has had SI joint trauma, tumor or infection. Moreover, SI joint fusion remains controversial for the treatment of chronic low back pain. More long term outcomes studies are needed to establish the safety and efficacy of SI joint fusion. In sum, SI joint fusion of the left side is not medically necessary for treatment of the patients medical condition. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  Three physician reviewers found that the request for Harvoni is medically necessary and is the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy. Therefore, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 inpatient hospital services for treatment of the enrollee, who was injured in a motor vehicle accident. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was admitted after a motor vehicle accident with multiple injuries, including a T5 vertebral burst fracture.  Subsequently, the patient was able to ambulate with a front-wheeled walker.  He was not requiring any parental medications, his pain was controlled, and he was not having any problems with voiding or eating.  The documentation does not support that the patient required the inpatient level of care at issue; he could have been treated at a lower level of care.  All told, inpatient hospital services at issue were not medically indicated for the treatment of this patient. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested bilateral magnetic resonance imaging (MRI) of the knees for evaluation of his knee pain. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested bilateral MRI of the knees in this clinical setting.  Per the submitted documentation, the patient has not been seen by an orthopedist in a significant amount of time.   A recent evaluation by an orthopedist is necessary to establish the medical necessity of the requested services.  All told, the requested bilateral MRI of the knees 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Patients with cirrhosis are considered highest priority for therapy.  This patient should be considered treatment-naive, as the only therapy attempted in the past was interferon monotherapy for one week.  In cirrhotic treatment-naive patients with hepatitis C, genotype 1 infection, therapy with Harvoni for 12 weeks is recommended.  Therefore, the requested Harvoni for 12 weeks is medically indicated for the treatment of this patient.   Final Result: Three reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hospital services on an emergent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient was involved in a high speed automobile accident. While the patients signs and symptoms were not severe, there was the potential for life threatening injuries sustained in the traumatic event. Therefore, a prudent layperson would have sought medical attention on the date of service in question because the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms met prudent layperson criteria for emergency care.Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi, Pegasys and ribavirin for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that according to the 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions.  For patients with HCV genotype 6, AASLD/IDSA guidelines recommend Sovaldi and weight-based ribavirin with peginterferon. In the phase III NEUTRINO trial, treatment-naive patients with HCV genotype 6 were treated with sofosbuvir plus peginterferon 2a  and weight-based ribavirin for 12 weeks. All six patients with HCV genotype 6 achieved sustained virologic response.  In addition, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Sovaldi, Pegasys, and ribavirin is medically necessary for 12 weeks in this patients case. Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified in gastroenterology and is 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: Upheld Decision of Health Plan

An enrollee has requested pelvic floor electrical stimulation for treatment of her urinary incontinence.  Nature of Statutory Criteria/Case Summary:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. This patient presents with symptoms of mixed incontinence of moderate severity with evidence of pelvic floor muscle laxity. A review of the medical literature suggests that in patients that have tried and failed pelvic floor training and weight loss in addition to medications, there is an indeterminate but possible benefit to non-implanted electrical stimulation if biofeedback has also failed. In this case, there is no documentation of weight loss consultation or medication use and the requested services would not likely prove more beneficial than standard therapies. For the reasons provided, pelvic floor electrical stimulation is not likely to be more beneficial than standard medical therapy in this clinical setting. 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: All three reviewers are board certified in urology 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 a hospital for treatment of his cyst of kidney and ureteric obstruction.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for a hospital stay has not been established. At the time of admission the patient had stable vital signs and was afebrile. There was no indication of active infection, the urinalysis was normal. There was no documentation submitted that showed hematuria, urinary tract infection or uncontrolled pain. The documentation submitted for review does not demonstrate that the patient had problems voiding, ambulating, eating or with pain management. Upon review of the documentation submitted, the patient could have been treated at a lower level of care.  As such, the documentation submitted for review does not support that the patient required services at an inpatient level of care. For the reasons provided, the services at issue were not medically necessary. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Nexium for treatment of her gastroesophageal reflux disease. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action, side effects, and cost characterize proton pump inhibitor variations.  No particular proton pump inhibitor can claim overall superiority, such that as a class proton pump inhibitors are interchangeable.  In this patients case, the available records do not support that her gastroesophageal reflux disease is advanced, nor has she demonstrated intolerance to specific proton pump inhibitors.  The records do not indicate that she has maximized treatment with step therapy.  All told, the requested Nexium 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 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 natural desiccated thyroid hormone replacement for treatment of her Hashimoto thyroiditis.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for natural desiccated thyroid hormone replacement has been established. The documentation submitted for review demonstrates that the patient has had improvement in her symptoms when switched to Armour Thyroid. The patient reports symptoms of headaches, nausea, gas and bloating and diarrhea and joint aches from levothyroxine. In this case, Armour Thyroid is likely to be safe as long as the levels are monitored closely. Given that the patient reports side effects from the levothyroxine it is reasonable and medically necessary for the requested medication. According to Ross Often, patients who are doing well symptomatically on a combination preparation (eg, Armour Thyroid) refuse to be switched to T4. As long as their thyroid function tests are normal and are monitored periodically, it is probably safe for them to continue to take the thyroid preparation they prefer. For the reasons provided, the patients request for natural desiccated thyroid hormone replacement is medically necessary.   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 endocrinology 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.