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 Nutropin AQ Nuspin 5 mg/2 mL pen injector for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that growth hormone deficiency is a medical condition in which the body does not produce enough growth hormone.  Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. Growth hormone replacement therapy can provide a number of measurable benefits to growth hormone deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In patients with known hypothalamic or pituitary disease, providers can establish the diagnosis of growth hormone deficiency with high sensitivity and specificity when there are three or four additional pituitary hormonal deficiencies or a sub-normal IGF-1 level. To establish the diagnosis in patients without these criteria requires provocative growth hormone stimulation. In this case, the patient meets the criteria for growth hormone deficiency as she has a low IGF-1 level, and mounted a sub-normal response to provocative testing with glucagon. Therefore, the request for Nutropin AQ Nuspin 5 mg/2 mL pen injector is medically necessary for treatment of the patients medical condition. 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 endocrinology, diabetes and metabolism 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 of Harvoni for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should be treated with Harvoni. These recommendations are based on multiple randomized clinical trials. The medication regimen is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. However, while treatment naive patients with viral loads less than 6,000,000 IU/mL can be treated for weeks, this regimen is not appropriate for patients who have previously failed therapy. In this patients case, the provided records do not report whether there has been hepatitis C treatment, and if so, which treatment was used. For these reasons, the requested treatment with Harvoni is not supported as medically necessary for the treatment of the patients hepatitis C infection. Final Result: The reviewer determined that the requested medication regimen 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that the patient was showing mild post-acute withdrawal symptoms, described as anxiety and cravings. He was not a danger to himself or others. He was medically and psychiatrically stable. He was motivated and was described to be working the program. He demonstrated insight in that he knew his triggers and barriers to recovery. His family and girlfriend were supportive, albeit described as enablers. His living environment was conducive to recovery. No new problems had arisen and no medication changes were made that required RTC level of care. The issues the patient was focusing on in individual psychotherapy could have continued on in an ambulatory setting. The patient no longer required 24-hour supervision, and could have been stepped down to PHP level of care. Thus, the RTC services provided were not medically necessary for treatment of this 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 psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stem cell fat grafting for treatment of the enrollees non-healing wound. Findings:  The 3 physician reviewers found that Although there is some evidence of benefit with stem cell fat grafting in irradiated wounds, specifically with respect to radiation changes following breast reconstruction, it is unclear if this same benefit could be expected with an irradiated open wound. According to colleagues Although autologous fat grafting has been shown to improve the quality and regenerative potential of chronically scarred tissues and burn scars, the effect on wound healing of chronic wounds and early-stage pressure ulcers has only been reported on sporadically. In addition, the American Society of Plastic Surgeons (ASPS) noted that Based on a review of the current literature and a lack of strong data, the task force cannot make specific recommendations for the clinical use of fat grafts.  Although there may be a possible benefit for the reparative potential of stem cell fat grafting, there is a lack of clinical evidence to support its use in this clinical setting. Therefore, the request for stem cell fat grafting is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The 3 reviewers determined that the requested service is 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: An enrollee has requested reimbursement for residential treatment center services provided and intensive outpatient program (IOP) services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that residential treatment center services provided were medically necessary for treatment of the patients behavioral health condition. According to the documentation submitted for review, the patient had mild to moderate post-acute withdrawal symptoms as well as intense cravings, erratic sleep, and requiring prompting to adequately attend to ADLs. For the reasons provided, the residential treatment center services provided were medically necessary.  However, there were no emotional, behavioral, or cognitive symptoms to warrant ongoing IOP. He was not a danger to himself or others. He was medically and psychiatrically stable. He was not agitated, nor was he manic or psychotic.  He verbalized motivation and appeared to be engaged and working the program. He was attending daily 12-step meetings and had secured a sponsor. There were no new problems that had arisen and he was working on issues with guilt and anxiety which could have continued on an outpatient basis. He no longer required recovery treatment that IOP provided. Based on the documentation submitted for review, the patient could have been treated at a lower level of care such as outpatient treatment in conjunction with a 12-step program and the support of his sponsor. For the reasons provided, the IOP services provided were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that a portion of the services at issue were 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 with sub-specialty certification in addiction 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 Otezla 30 mg (maintenance dose) twice daily for treatment of the enrollees psoriatic arthritis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not demonstrate where the joint disease is active but it is assumed to be peripheral. The Group for Research and Assessment of Psoriasis and Psoriatic Arthritis (GRAPPA) states the following, Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and TNF inhibitors,. Anti-tumor necrosis factor alpha agents have been proven very effective for PsA and are disease modifying agents. They prevent progression of disease, erosions and disability and are the preferred agent for PsA (EULAR 2015 Update). Otezla (apremilast) is an orally administered phosphodiesterase-4 inhibitor available for the treatment of PsA but it is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA (EULAR 2015 Update).  Therefore, the request for Otezla 30 mg (maintenance dose) twice daily for this patients medical condition is not medically necessary for 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 and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for prostatic urethral lift procedure performed for treatment of the enrollees benign prostatic hyperplasia (BPH) and nocturia. Findings:  2/3 of the physician reviewers found that the prostatic urethral lift procedure has been approved as an effective treatment of appropriately selected patients who are 50 years of age or older with benign prostatic hyperplasia.  This procedure has shown to be safe and effective in the short term. There is good quality evidence to establish the efficacy of the prostatic urethral lift procedure in treating symptomatic benign prostatic hyperplasia without adversely affecting quality of life. The prostatic urethral lift procedure is an appropriate treatment option for those symptomatic benign prostatic hyperplasia patients who failed medical therapy or are intolerant to it and wish to preserve their sexual function.  Thus, the prostatic urethral lift procedure performed was likely to have been superior over other options for the treatment of this patients medical condition. Final Result: 2/3 of 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: The reviewer is board certified in urology 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 63-year-old female enrollee has requested authorization and coverage for an office consultation and follow up visit with a bariatric surgeon for evaluation of the enrollee who has a history of grade II endometrial cancer and obesity. Findings:  The physician reviewer found that there is support in the medical literature for the requested services in this clinical setting. Late complications of Roux-en-Y gastric bypass can include dumping syndrome, anastomotic stricture, intussusception, gallstone disease, pain, fistula, ulcer, weight regain, and nutritional deficiencies including B vitamins, iron, calcium, copper, vitamin D, selenium, zinc, and vitamin A. The epigastric abdominal pain that required evaluation in the emergency department in July 2017 may have been caused by a number of these complications. These complications are best evaluated by a bariatric surgeon, who is trained to recognize common and uncommon postsurgical complications.  Therefore, the office consultation and follow up visit with a bariatric surgeon are supported as medically necessary for the evaluation of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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: An enrollee has requested authorization and coverage for acupuncture for treatment of the enrollees tinnitus.Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting.  The studies that support acupuncture as an effective therapy for chronic tinnitus are not based on evidence of rigorous randomized controlled trials. The medical research does not show statistical significant differences between the acupuncture group and the placebo group. Further research on this subject seems to be warranted but should be conducted according to the highest methodological standards.  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 oriental 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 Xarelto  for treatment of the enrollees deep vein thrombosis. Findings:  The physician reviewer found that in this circumstance anticoagulation is clinically indicated.  Initial anticoagulation can include subcutaneous low molecular weight heparin or fondaparinux and the data suggests similar efficacy with direct oral anticoagulants such as Xarelto. Longer term anticoagulation with warfarin is also of similar efficacy compared to that of oral factor inhibitors such as Xarelto. Given that the formulary alternatives available have similar efficacy, Xarelto has not been established as medically necessary for treatment of the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cervical C6-7 anterior cervical discectomy and fusion surgery for treatment of the enrollees C6-7 herniated disc.Findings:  The physician reviewer found that according to the prospective, randomized study of patients with cervical radiculopathy, it was shown that surgery with physiotherapy resulted in a more rapid improvement during the first postoperative year, with significantly greater improvement in neck pain and the patient's global assessment than physiotherapy alone. In this case, the patient has tried conservative treatments with no relief. Therefore, based on a review of the current peer literature and medical documentation submitted, the proposed cervical spinal fusion and associated procedures is indicated for this patient. However, the request for the surgery to be provided by an out-of-network provider is not medically necessary. Final Result: The reviewer determined that the requested surgery on or before 8/10/17 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 neurological 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 reimbursement for nasal surgery for treatment of the enrollee, who was status post septorhinoplasty. Findings:  The physician reviewer found that this patients case, there is well-documented evidence of nasal breathing problems from a previous septorhinoplasty. Her symptoms, clinical examination findings and photographs are consistent with partial nasal obstruction. The operative report is consistent with the preoperative plan for correction of functional impairment. There was evidence of internal and external nasal valve collapse, as well as septal deviation and septal spine dislocation. The records document clinically significant nasal obstruction from a predictable pattern of deformity and impairment. Rhinoplasty with septoplasty would be consistent with standard of care in the setting of residual nasal deformity and nasal airway obstruction as a result of her condition.  All told, nasal surgery performed was medically necessary for the treatment of this patient. Final 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 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.