Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the UroLift procedure for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested services.  The UroLift procedure is at best a temporary solution in this clinical setting.  There is a lack of peer-reviewed double-blinded studies which demonstrate that the UroLift procedure is more effective than transurethral resection of the prostate.  In sum, the requested UroLift procedure is not likely to be of greater benefit than other treatment options in this patients case. Final Result: Two 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:  The parent of an enrollee has requested residential treatment center services for the treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient is described as being intelligent, having both internal and external motivation to do well in the program.  He was described as being ready for treatment.  The records do not document prior substance abuse treatment other than outpatient dialectical behavior therapy.  He was not suicidal or homicidal.  The current medical evidence does not support the services at issue in this clinical setting.  All told, residential treatment center services 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 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 Viekira Pak for treatment of his hepatitis C virus.  Findings:  The physician reviewer 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 due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks, or with Harvoni for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety with either medication.  However, there is a lack of head-to-head trials showing that Viekira Pak is superior to Harvoni, which is the Health Plans alternative.  For these reasons, although treatment of hepatitis C is necessary in this case, the requested treatment with Viekira Pak is not supported as medically necessary for the treatment of this patients hepatitis C infection.   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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of his medical condition.   Findings:  The physician reviewer found that an MRI is an optimal means to evaluate an internal derangement but the question of when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is important.  As discussed by Miller An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films. Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms. Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require an MRI and may require referral to an orthopedist as a next step in the evaluation. However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. In this particular patient, the submitted documentation shows no evidence of objective signs such as an effusion or instability that would have warranted an MRI. Based upon the records provided, only mild fissuring of the cartilage was noted, without evidence of a meniscal or ligamentous injury. Evidenced based studies regarding the use of MRI of asymptomatic knee injury recommend a conservative trial of therapy prior to imaging. In this case, the submitted documentation fails to demonstrate that a trial of conservative treatment was attempted by the patient without relief of his symptoms. For these reasons, the services at issue were not medically necessary for the evaluation of the patients knee pain. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a bone graft for treatment of her medical condition.   Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  The provider indicated that the patient had an existing bridge which had failed, and the treatment plan was developed for an implant to replace one of the missing teeth.  The provider reported that the bone was of inadequate height for implant placement, requiring a graft to augment the ridge in the area of the sinus.  The requested service code is used for periodontal regeneration when the periodontal disease process has led to a deformity of the bone adjacent to a tooth.  This code generally requires diagnosis of type III or type IV periodontal disease.  There is no evidence of periodontal disease present requiring this grafting procedure.  In sum, a bone graft was 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 dentistry 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 inpatient hospitalization for treatment of her behavioral health conditions. Findings:  The physician reviewer found that submitted documentation supports a portion of the services at issue.  Documents from day to day seem to be very similar, with some changes to verbiage and some sentences remaining identical throughout the entire hospitalization period, making it difficult to assess what was actually done on a day to day basis to treat the patient.  The records do not provide detailed updates regarding her response to this therapy, and no adjustments to a failing plan were initiated by the treating psychiatrist.  The records do not indicate that specialized therapy was introduced or mentioned for chronic depression.  Therapy notes did not indicate significant progress in intensive dialectical behavioral therapy.  The records indicate that the patient could have been safely treated at a lower level of care once the patient was somewhat more stable after admission.  In sum, initial inpatient hospitalization was medically indicated for the treatment of this patient.  However, the medical records fail to demonstrate the medical necessity of inpatient hospitalization provided thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 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 Trokendi XR for treatment of her medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Topiramate is indicated for migraine prevention, and has evidence for being effective for chronic migraine. However, there are a variety of common side effects with topiramate, including paresthesia, fatigue, and cognitive changes. Trokendi is an extended release formulation of topiramate.  Trokendi has been shown to be favorable in terms of side-effects compared to immediate release topiramate. In this case, the patient has been treated with Topamax (topiramate) and it was discontinued due to side-effects. There is a lack of documentation provided demonstrating that Topamax had been beneficial, even at higher doses. Moreover, Botox which has been recommended by the provider is indicated for chronic migraine, with good data regarding effectiveness and tolerability. Botox is reasonably appropriate and likely to have superior results compared to topiramate, which she has previously tried. Therefore, the request for Trokendi XR 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 Physician reviewer is board certified in neurology 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 plus ribavirin for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to nonliver-related conditions. The guidelines recommend that patients who have failed therapy with an NS5A inhibitor (such as Viekira Pak) should undergo testing for resistance-associated variants.  In cases with lack of NS5A resistance, such as this one, the guidelines recommend re-treatment with Harvoni and ribavirin for 24 weeks.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer 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: The physician reviewer is 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 magnetic resonance imaging/magnetic resonance angiogram (MRI/MRA) for evaluation of her medical condition.  Findings:  The physician reviewer found that thoracic outlet syndrome (TOS) refers to a group of clinical syndromes caused by congenital or acquired compression of the brachial plexus (neurogenic TOS) or subclavian artery or subclavian vein as they pass through the thoracic inlet.  There are multiple modalities utilized to diagnose TOS. These include ultrasound, plain radiographs, contrast-enhanced computed tomography (CT), MRI, or conventional angiography. MRI has become popular in its ability to simultaneously demonstrate the vasculature, bones, and soft tissues, in multiple different projections. As noted by Demondion and colleagues The thoracic outlet includes three compartments (the interscalene triangle, costoclavicular space, and retropectoralis minor space), which extend from the cervical spine and mediastinum to the lower border of the pectoralis minor muscle. Dynamically induced compression of the neural, arterial, or venous structures crossing these compartments leads to thoracic outlet syndrome (TOS). The authors further state that clinical diagnosis is often difficult and that MR imaging remains the method of choice when searching for neurologic compression. Aghayev and Rybicki concur stating The use of contrast-enhanced [three-dimensional] 3D MRA provides comprehensive information on arterial and venous compression by surrounding organs. In this case, the patient has previously undergone extensive evaluation and has tried multiple conservative therapies. The vascular surgeon has elicited evidence of vascular compromise (decreased radial pulses and bruits) with changes in position. In this clinical setting it is medically necessary to investigate the anatomy and determine whether surgery is an additional viable option. Based on the peer-reviewed literature and clinical documentation, the requested services are clinically indicated for this patient.  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 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 treatment of her hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for 8 weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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 Viekira and Ribasphere for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety; the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al; Poordad, et al; Ferenci, et al). For these reasons, the requested treatment with Viekira Pak and Ribasphere is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition.  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 a continuous passive motion device for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue.  The records document that this patient underwent right knee, right medial patellofemoral ligament reconstruction. There is no documentation of complex regional pain syndrome, significant arthrofibrosis or tendon fibrosis, or inability to participate in active physical therapy to support the medical necessity of the continuous passive motion device consistent with evidence based peer-reviewed guidelines. There is no compelling rationale presented to support the medical necessity of the continuous passive motion device.  All told, the equipment at issue was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue was 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested frontal bone lesion removal surgery for treatment of his medical condition. Findings:  The physician reviewer found that according to the peer-reviewed literature, in this clinical setting indications for surgery include a rapidly growing lesion or one that occludes/obstructs the sinonasal drainage system (Ehieli, et al; Turri-Zanoni, et al). According to Turri-Zanoni and colleagues a wait and scan policy is the therapeutic standard. In this case, the patient presents with an incidental, benign appearing left frontal skull lesion. There is no surrounding reaction to the lesion. Moreover, the lesion has not increased in size as noted on successive radiographic studies. In addition, the lesion has not obstructed the sinonasal drainage system. All told, the requested services are 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 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.