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 Zepatier 50-100 mg tablets for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. 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 HCV should be treated, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or 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, the request for Zepatier 50-100 mg tablets for 12 weeks is supported as medically necessary for the treatment of this patients HCV, genotype 1a 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for liposuction of the abdomen. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. Liposuction of the lateral abdomen is medically indicated in this clinical setting.  This patient has a significantly abnormal appearance due to previous treatments. Liposuction is an appropriate intervention in order to correct this abnormality.  In this patients case, the requested services are reconstructive in nature. This patients condition constitutes an abnormal structure of the body. The records document lateral abdominal excess following breast reconstruction using an abdominal flap. Although the requested surgery is not likely to improve function, it is likely to create a normal appearance to the extent possible. The requested liposuction of the abdomen is likely to provide more than a minimal improvement in the appearance of the patient. Therefore, the requested services are reconstructive in nature. All told, the requested liposuction of the abdomen is medically necessary and is reconstructive in nature.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested reimbursement for residential treatment center (RTC) services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings:  The physician reviewer found that according to the documentation provided for review, the patient remained symptomatic during the dates in dispute. The American Academy of Child and Adolescent Psychiatry (AACAP) Child and Adolescent Service Intensity Instrument (CASII) was developed to help determine the appropriate level of service intensity for behavioral health treatment for children and adolescents. The CASII utilizes dimensions that are relevant to the patients clinical status when determining appropriate level of service intensity. These dimensions include risk of harm, functional status, co-occurrence, environmental stress and support, resiliency and/or response to services, and child/adolescent and parent involvement in services. In this case, the providers noted that the patient was highly distractible and struggled with mood lability, impulse control, poor insight, emotion regulation, and at times expressed thoughts of wanting to die. She remained on 15-minute safety checks throughout her admission. Based on the patients clinical history and documentation provided for review, the patient met CASII criteria for non-secure 24-hour psychiatric monitoring. Thus, the patients clinical status, in addition to current medical literature, support that the RTC level of care services provided were medically necessary for treatment of the patients medical conditionFinal Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a quantity increase of Vicodin HP 10/300 mg eight tablets per day, two tablets every six hours as needed, a total of 240 tablets per month for evaluation of the enrollee's migraines. Findings:  The physician reviewer found that the current medical evidence does not support the requested medication quantity in this clinical setting. Opiates should be used sparingly, if at all, in the therapy of migraines. The chronic use of opiates may lead to medication overuse headaches as well as transformed headaches. While this patient states he is able to function better with this medication, the long-term risks are substantial. All told, the requested quantity increase of Vicodin HP 10/300 mg eight tablets per day, two tablets every six hours as needed, a total of 240 tablets per month is not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 reimbursement and prospective authorization and coverage for continued skilled nursing care including physical therapy and occupational therapy. The documentation does not show that the patient had continued medical needs for SNF services. The documentation does not reveal complex wound care, enteral feeds or ventilator dependence. The patient does not require skilled nursing services to prevent a deterioration in his condition or skilled nursing services to establish a safe and effective maintenance program. The documentation does not reveal that the patient requires skilled therapy services on a daily basis or skilled nursing services on a daily basis. The documentation reveals that the patients gradual progress in recent therapy and his current functional condition do not require daily SNF level skilled therapy. He does not require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care. The patient does not require services on a daily inpatient basis, at a SNF level of care. All told, the skilled nursing care including physical therapy and occupational therapy was not and is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 reimbursement for OxyContin and oxycodone. In the documentation available for review, this patient presented with postsurgical pain. However, the records document that the patient was on several medications prior to surgery that were continued in the postoperative period that were not opioids. In addition, not all non-opioid treatment options were utilized to the highest effective dose. Specifically, gabapentin is not the highest effective dose of this medication. Moreover, it is reasonable to consider alternatives to opioids. The current evidence based research does not support primarily opioid focused therapy as treatment for shingles. Furthermore, no objective treatment goals for pain and function are noted for the medications at issue. For these reasons, the OxyContin and the oxycodone were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medications 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-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 authorization and coverage for alprazolam 2 mg. The newly synthesized benzodiazepine class of medication effectively supplanted barbiturates as the mainstay of psychopharmacologic treatment of anxiety.  Findings:  The physician reviewer found that Although safer than their predecessor, the benzodiazepines possess an array of potential side effects.  Disinhibition, cognitive dulling, perceptual disturbances and exacerbation of depression are common, while a connection with Alzheimers disease later in life has been suggested in the peer-reviewed literature.  Additionally, there is growing concern of misuse, tolerance and dependence issues with this medication class. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. These basic pharmacokinetic and pharmacodynamic properties make alprazolam a particularly addictive benzodiazepine. Contemporary practice standards aim to minimize benzodiazepine therapy and optimize treatment alternatives, particularly in patients with history of addictive illness. The submitted documentation fails to demonstrate the medical necessity of the requested medication. In terms of medication alternatives, the patient has been prescribed a longer-acting, less addictive benzodiazepine which is a safe, appropriate, standard practice intervention. Further, with a fairly conservative dose of sertraline and many other medications to choose from, he has not failed an adequate trial of pro-serotonergic medicines, which represent first-line interventions for generalized anxiety disorder and major depressive disorder. Additionally, it does not appear that the patient has pursued trusted non-pharmacologic interventions, such as chemical dependency counseling, psychodynamic psychotherapy or cognitive behavioral therapy for anxiety and/or depression. Based on the documentation provided, the patient has not exhausted evidence-based medication options or non-pharmacologic treatment alternatives to address his depression and anxiety, while the requested medication carries an unfavorable risk-benefit profile. Thus, alprazolam 2 mg is not medically necessary 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha Sureclick pen injector. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollee who has a history of hyperlipidemia and hypertension.Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the requested medication in this clinical setting. Based on the records provided, the patient has known coronary disease and hyperlipidemia intolerant of two statin medications. Repatha (evolocumab) is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. According to the submitted records, this patient does not fit either of those criteria.  Specifically, there is no documentation to support the patients LDL is above goal while on an adequate trial of Zetia medication. In addition, other statin medications, such as pitavastatin and fluvastatin, have lower side effect profiles and have not been documented to be tried or not tolerated in this patient. For these reasons, the request for Repatha Sureclick pen injector has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested authorization and coverage for Mavyret . The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus .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, regardless of fibrosis stage, except those with limited life expectancy due to non-liver-related conditions. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C.  guidelines cite data showed reduced survival with delayed treatment. For these reasons, the request for Mavyret is supported as medically necessary for treatment of this patients chronic 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. Findings:  The physician reviewer found that
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for a gene test (MammaPrint). The Health Plan has denied this request indicating that the testing at issue was considered investigational for evaluation of the enrollees breast cancer.The gene test (MammaPrint) provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Amsterdam 70-gene prognostic profile was one of the first gene expression arrays approved for commercial use (MammaPrint). The clinical validity of the 70-gene prognostic profile has been demonstrated in multiple studies. Results from an international randomized trial suggest that this genetic profile may identify subsets of patients who have a low likelihood of distant recurrence despite high-risk clinical features. Based on a randomized trial, American Society of Clinical Oncology has suggested MammaPrint is one of several assays that might be used to determine prognosis for those with high clinical risk, hormone receptor-positive, HER2-negative breast cancer and no or limited (one to three) involved lymph nodes to inform decisions regarding withholding chemotherapy. For the reasons provided, 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 of the three 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: Physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for anesthesia services (CPT 00740). Findings:  The physician reviewer found that the monitored anesthesia services were not medically necessary during the patients endoscopy/colonoscopy. 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. A systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in colonoscopy concluded that when moderate sedation is utilized, there is a high level of physician and patient satisfaction while providing low risk of serious adverse events with all currently available agents. In an article, the authors noted that not all procedures are well suited for the office with sedation. Unacceptable procedures would include those associated with significant fluid shifts, postoperative pain, bleeding or procedures of long duration. Studies noted, Since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts of significant post-procedure discomfort; in appropriate patients, these procedures are well suited to office-based practice. However, in this case, the patient did not present with a significant history that would have required monitored anesthesia care. There was no documentation of comorbid conditions that would have placed this patient at risk for complications requiring the need for monitored anesthesia care. Upon review of the patients medical records, the patient did not meet the criteria for monitored anesthesia care. Therefore, anesthesia services (CPT 00740) provided were not medically necessary for management of this patients pain during a routine endoscopy/colonoscopy. 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-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.