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

Findings:  The physician reviewer found that the patient has history of hepatitis C and arthritis. Her physician ordered Mavyret for 8 weeks. The Health Plan denied the request as not medically necessary. At issue is in this case is whether the medication Mavyret 100/40 mg for eight weeks is medically necessary for the treatment of the patient's medical condition.Per recent medical literature, Mavyret is indicated in patients with hepatitis C, genotype 1, for both new treatment and for experienced patients. Mavyret has been shown to result in 99 percent sustained viral response rate for the 8 and 12 week regimens. According to the Food and Drug Administration (FDA), Mavyret is the first product with a recommended eight week course of therapy for chronic hepatitis C viral infection. This for infection caused by viral genotypes 1-6 in treatment-naive adults without cirrhosis. In this case, the documentation supports the diagnosis of hepatitis C in this patient. The patient has not been treated for hepatitis C. The patient meets the FDA indications for treatment with Mavyret. Therefore, the requested medication Mavyret 100/40 mg for eight weeks 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 internal medicine with subspecialty certification in infectious 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: An enrollee has requested authorization and coverage for a magnetic resonance imaging (MRI) of the brain. Findings  The physician reviewer found the submitted documentation supports the requested MRI as medically necessary.  Intracranial meningiomas can recur after surgical resection. In addition, residual enhancement at the surgical site can be difficult to distinguish between tumor recurrence and sequela of surgery. Follow-up MRI is appropriate in these clinical situations to assess interval growth or changes over a period of time. On comparison of this patients 2016 and 2017 MRI studies, there was abnormal enhancement suspicious for lesion recurrence. Repeat MRI should be performed to assess the interval change of the abnormal enhancement. Based on these findings, the requested MRI of the brain is medically necessary for evaluation of this patients intracranial meningioma. Final Result: The reviewer determined that the requested service is 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 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: The parent of a patient has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for up to 45 days. Findings:  The physician reviewer found that at the time of admission to the RTC, the patient continued to endorse passive ideas of suicide similar to those she had twice before acted upon. Although she was not observed to binge or purge in the hospital, she had documented weight fluctuations, indicating covert manipulation of intake and likely of elimination as well. She was not stabilized on an appropriate medication regimen. She remained dysphoric, anxious, and with sleep disturbances. Applying the Child and Adolescent Level of Care Utilization System (CALOCUS), the composite score for this patient is 20, which indicates that the patient can be safely and adequately treated in a non-secure facility with psychiatric monitoring and 24-hour services, consistent with RTC level of care. However, such services should be in close proximity to the patients home. Additional CALOCUS determinates include (4) serious risk of harm in a patient with persistent thoughts of dying and a recent history of suicidal behavior; (3) moderate functional impairment with school failure and absenteeism due to panic; (1) no co-morbidity; (3) stressful recovery environment; (4) minimal support environment with father in denial and mother in different state; (3) difficulty engaging in treatment; and (2) constructive acceptance of treatment by the patient. All told, continued residential treatment, for up to 45 days, was and is medically necessary for treatment of this patients behavioral health issues. 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 psychiatry with subspecialty 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 the medication Copaxone Syringe 40 mg/mL. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Mitsikostas and colleagues have reflected that glatiramer acetate (GA), an FDA-approved therapeutic equivalent to Copaxone, is an effective treatment for multiple sclerosis with a side effect profile that is better than comparable treatments for multiple sclerosis. In their comparison of therapies, there was no indication of an advantage of brand type over generic type. In this case, while the patient has noted a concern for potential side effects related to the generic equivalents to Copaxone, there is no indication to favor brand name Copaxone over its therapeutic equivalents. The submitted records reflect that the patient has been diagnosed with multiple sclerosis (MS) and was started on a generic equivalent to Copaxone and has not demonstrated any side effects or allergies related to the medication. Under these circumstances, Copaxone Syringe 40 mg/mL is not medically necessary for 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 neurology, with subspecialty 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for spine surgery on the neck.Findings:  Two of the three physician reviewers found that the medical evidence supports the requested services in this clinical setting. There are significant benefits documented in the literature with respect to total disc replacement which results in improved general and disease-specific outcome measures and a lower rate of reoperation in the two-level disc replacement patients versus two-level anterior cervical discectomy and fusion control patients.  With regards to the long-term results of cervical total disc replacement, there are significant benefits over the conventional multilevel anterior cervical discectomy and fusion. There is motion preservation, decreased incidence of adjacent segment disease, improved clinical outcome and decreased need for revision surgery. The requested services are likely to be more beneficial for treatment of this patient than the standard two-level anterior cervical discectomy and fusion. Thus, the requested spine surgery on the neck  is likely to be more effective than other treatment options.Final Result: The reviewers determined that the requested services are likely to be more beneficial for the treatment of the enrollees medical condition than any available standard therapy. The Health Plans denial is overturned. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery 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 acupuncture. The submitted documentation and medical literature support the present request for acupuncture. In a 2007 study of the efficacy of acupuncture in myofascial pain syndrome, Ga and colleagues concluded that there was no significant difference between acupuncture needling and 0.5% lidocaine injection of trigger points for treating myofascial pain syndrome. In a 2009 study, researchers investigated the remote effect of acupuncture on the pain intensity recorded from a myofascial trigger point of the upper trapezius muscle, and their results were that the pain intensity in the myofascial trigger point was significantly reduced after remote acupuncture, but not after sham acupuncture. In a subsequent 2011 study involving the remote effect of acupuncture in the upper trapezius muscle, Chou and colleagues found that immediately after acupuncture, all measured parameters improved significantly, but not in the placebo control group. In this case, there is no indication that the patient has yet undergone an acupuncture trial. Given that the patient continues to be significantly symptomatic despite previous care (oral medication), acupuncture for pain management and function improvement would be reasonable and is supported by the peer reviewed literature. Under these circumstances, acupuncture services are medically necessary for treatment of the patients medical condition.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 a licensed acupuncturist and a doctor of oriental medicine. 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 patient has requested authorization and coverage for a referral for treatment at a trauma based residential treatment center (RTC). Findings:  The physician reviewer found that the American Psychiatric Association (APA) practice guidelines note that indications for hospitalization include dangerous, impulsive behavior unable to be managed with outpatient level of care and complex comorbidity that requires more intensive clinical assessment of response to treatment. This patients symptoms are of sufficient severity to warrant RTC level of care as she has been unresponsive to outpatient and IOP levels of care. As noted in the medical literature, the authors discussed the promise of dialectical behavior therapy (DBT) for PTSD stemming from childhood abuse. The authors noted that DBT within an RTC program can help address the chronic nature of PTSD stemming from childhood abuse. As demonstrated in the records provided for review, the severity of the patients illness and failure of outpatient therapy supports the medical necessity of the requested treatment at a trauma based RTC. 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 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: The enrollee has requested reimbursement for anesthesia services. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees family history of colon cancer.At issue is whether the anesthesia services provided were medically necessary. Most lower endoscopy can be accomplished with either no, moderate, or deep sedation; general anesthesia and active airway management are rarely needed. Propofol-based sedation has advantages in terms of satisfaction and recovery over other modalities, but moderate sedation using benzodiazepines and opiates works well for low-risk patients and procedures. No sedation for routine colonoscopy works well for selected patients and eliminates sedation-related risks. There is no difference in outcome measures based on sedation received. Researchers noted that anesthesia assistance has potential complications including aspiration pneumonia but increased patient satisfaction in some cases.The patient has a family history of colon cancer but is otherwise healthy and may be classified as an ASA I patient for anesthetic purposes. MAC (monitored anesthesia care) anesthesia is medically necessary for patients with severe medical conditions including heart and lung disorders and not for relatively healthy, ASA I patients. The medically necessity of monitored anesthesia care cannot be justified in this case. Thus, the anesthesia 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 29-year-old female requested reimbursement for air and associated ground ambulance transportation. Findings:  The physician reviewer found that The enrollee has f a history of anorexia nervosa for the past 10 years; brought to the emergency room with altered mental status; lethargic; bradycardic; hypotensive and hypothermic and was admitted to the intensive care unit. She was air transported in transfer to a facility where she had previously been treated for noted medical state at the time requiring continuous medical management.The patient had stabilized somewhat at the point of transfer and although important that she gets to an eating disorder facility. Air Ambulance transport is generally used for transport to the nearest facility or sometimes to get one to a particularly hyper-specialized medical facility that is more distant but only when in a medically unstable state. The patient could have either waited to be further stabilized to the point of not needing continuous medical care or if so ill as to needing medical transport, a nearer facility could have conceivably been located. Transport services were not in accordance with generally accepted standards of medical practice appropriate for the patient's illness and were therefore not medically necessary.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 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: Urgent Care
Decision: Overturned Decision of Health Plan

The parent of the enrollee has requested reimbursement of psychiatric emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. The records indicate that the patient had a recent history of significant depressive and eating disorder symptoms. The patient was also refusing to attend school and behavioral health therapy. These represent acute mental health symptoms. They suggest a possible psychotic episode and affect the patients ability to care for himself. The patient therefore had a psychiatric emergency medical condition, and the care provided was intended to treat that condition. 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 psychiatry with subspecialty 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a Cologuard gene test.Findings: Two of the three physician reviewers found that conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against what is viewed as the gold standard, optical colonoscopy. Cologuard is a stool DNA test that includes molecular assays for DNA mutation and methylation biomarkers and a non-DNA immunochemical assay for human hemoglobin. Given the low sensitivity of Cologuard in detecting adenomas, the superior efficacy of the services at issue has not been established. The submitted records do not support that more effective conventional screening strategies were contraindicated in this patients case. Thus, the Cologuard test provided to the patient was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Two of the three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any other available standard treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  All three reviewers are board certified in internal medicine, with subspecialty 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections for both knees. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. As noted by researchers, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement. Researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections for both knees are medically necessary to treat the patients medical condition at this time.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 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.