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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a ProAir HFA albuterol inhaler for treatment of her medical condition.  Findings:  The physician reviewer found that the requested medication has not been established as medically necessary for treatment of the patients medical condition. The management of asthma per the Global Initiative for Asthma (GINA) guidelines divide asthmatics by their degree of control and based on that determine what step of treatment they require. All five steps have as their foundation the use of short acting beta agonists (albuterol) to achieve immediate relief during an acute worsening of asthma symptoms. The efficacy of short acting beta agonists for the management of acute asthma is long proven. In this case, the patient is requesting ProAir, an ethanol containing preparation. However, she has been authorized for treatment with Ventolin HFA albuterol. There is lack of rationale supporting this request or evidence of treatment failure. All told, ProAir HFA albuterol inhaler 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 pulmonary disease and critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Latuda for treatment of her behavioral health conditions. Findings:  The physician reviewer found that Lurasidone is an atypical, or second generation, antipsychotic medication initially approved for the treatment of schizophrenia.  In mid-2013, Latuda gained two additional indications, both for the treatment of bipolar illness.  There have been several studies demonstrating the clinical benefit of atypical antipsychotics in treating unilateral depression.  The data at this point best supports aripiprazole and quetiapine, followed by risperidone and olanzapine.  At this time, the peer-reviewed medical literature does not support Latuda as a first-line pharmacological treatment intervention for major depressive disorder.  Considering that the record does not demonstrate treatment failure of well-established augmentative strategies, such as buspirone, aripiprazole, quetiapine, olanzapine-fluoxetine, lithium or thyroid hormone, while the status of non-pharmacologic interventions such as an evidence-based psychotherapy for major depressive disorder is unclear, the medical necessity of the requested medication has not been established.  Therefore, the requested medication Latuda is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 breast augmentation and vascular surgery pre-operative consultation/clearance for treatment of her gender dysphoria. Findings:  The physician reviewer found that based on her response to hormone therapy, the patient presents with sufficient breast development to be considered consistent with adult female anatomy. Thus, breast augmentation surgery would be considered aesthetic and not medically necessary. As such, the requested vascular surgery pre-operative consultation/clearance is also not medical necessity for treatment of the patients medical condition. With regard to the whether the requested services are considered reconstructive in nature, the submitted documentation reveals the patient has relatively normal female breast development. The patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. As such, the patient does not present with an abnormal structure of the body. Thus, the requested breast augmentation is not reconstructive in nature for treatment of the patients gender dysphoria. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Helios braces for treatment of her peripheral neuropathy.   Findings:  Two physician reviewers found that the comprehensive rehabilitation of patients with Charcot-Marie-Tooth disease includes the use of properly fitted ankle foot orthosis (AFO) devices. These devices can reduce stumbling, tripping, or falling due to weakness and sensory deficits distal to the knee joint. In addition, properly fitted AFO devices may significantly reduce the need for proximal compensations and can improve lower extremity control during ambulation. Dynamic AFO devices also help reduce the energy expenditure of ambulation in patients with Charcot-Marie-Tooth disease (McCorquodale, et al). Further, in hemiparetic patients, dynamic AFO devices help compensate for foot drop as analyzed muscle activity was closer to a normal gait pattern when the dynamic AFO devices were worn (Zollo, et al). The records indicate that this patient experiences functional deficits secondary to bilateral foot drop. Her provider recommended Helios custom AFO devices to appropriately fit her individual needs for comprehensive disease management and rehabilitation goals. The Helios dynamic carbon-fiber AFO devices recommended are likely to provide this patient with a superior health outcome when compared to standard available alternatives and should therefore be approved.  Final Result: Two reviewers determined that the requested equipment is 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: All three reviewers are board certified in physical medicine and rehabilitation 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 for facial laser hair removal for treatment of her gender dysphoria.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient has been diagnosed with gender dysphoria. The presence of male pattern facial hair is contributing to the patients gender dysphoria. Thus, facial laser hair removal is medically necessary for treatment of her medical condition. Further, facial laser hair removal is considered reconstructive in this setting. The presence of facial hair in a female would be considered abnormal and is referred to as hirsutism. The `abnormal` hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested laser hair removal procedure will create a more normal feminine facial appearance. Further, the requested laser hair removal procedure can provide substantial improvement in the appearance of the patients terminal hair. As such, the requested service is considered reconstructive in this clinical setting. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in dermatology 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 the enrollees 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, and advanced fibrosis is not required for treatment. 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 eight weeks, as in this case. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks 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 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 the medication Tecfidera 240 mg capsule for treatment of the enrollees multiple sclerosis. Findings: The physician reviewer found that Tecfidera is U.S. Food and Drug Administration (FDA) approved for relapsing forms of MS. This patient has active MS and needs to be on a therapy that is likely to be more effective than an interferon. In addition, she has had significant injection site reactions and would prefer to be treated with an oral agent. Moreover, the patient has been on Tecfidera for three months and is tolerating it well. Given this support, the requested Tecfidera 240 mg capsule is supported as medically necessary for treatment of this patients MS.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 and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested home care (private duty nursing) for treatment of the enrollees mitochondrial disorder.  Findings: The physician reviewer found that, upon review of the record, the submitted documentation fails to demonstrate the medical necessity for the requested services. Current treatment for patients with mitochondrial disease remains supportive. Issues that may require evaluation and intervention include respiratory failure, seizures, cardiomyopathy and conduction defects, ophthalmoplegia, neurologic deficits (including dysarthria, dysphagia, weakness, spasticity, and/or ataxia), and cognitive impairment. In this case, the patient appears stable without any acute concerns or recent complications. The documentation does not support that she has had any complications including infections, skin problems or recent injuries. The patient requires assistance with ADLs including bathing and toileting, but these tasks can be performed by a non-skilled person. The records show the patient is able to tolerate an oral diet but also receives liquid dietary supplements and medications via a feeding tube. Moreover, the documentation does not support that the patient requires any physical, speech or occupational therapy. She is at her baseline functional status. The patient has been stable without any recent illness or injury documented. The records do not show that the patient requires any skilled nursing needs and she does not require any complex wound care. The administration of nutrition and medications via a feeding tube and care for a tracheostomy can be performed by a non-skilled person. Therefore, in light of the submitted records, the requested services for treatment of this patients chronic medical condition are 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation supports the services at issue for this patient. Standard practice regarding treatment referrals usually progress in a step-wise fashion from less to more restrictive settings; however, episodically bypassing intermediate levels of care may often be clinically appropriate. Relating these general concepts to this particular dispute, this combat veteran had co-occurring alcoholism and mental illness. The patient had recently endured two dramatic work-related violent events that exacerbated his symptom complex. The diagnosis of PTSD is characterized by a pathological inability to feel safe, and these events, occurring within the patients social network and place of employment, served to fortify the distorted cognitive schemas that fuel the impairment of the condition.  Despite a supportive family, prior residential treatment and a sober living residence, he was consuming excessive alcohol.  He was having social impairment, medical sequelae and intrapsychic distress due to his drinking.  Moreover, the patients depression and PTSD were significant, yet untreated.  On presentation, the patient was anxious, labile and depressed.  During his admission, the patient has received evidence-based treatment and aggressive pharmacotherapy aimed at addressing the patients convoluted relationship with alcohol and mobilizing the meaningful therapeutic momentum needed to foster sustained sobriety. Although the patient had not engaged treatment in a less restrictive setting during the episode of illness, considering the confluence of biological and psychosocial factors, treatment at a setting less intensive than residential would be inadequate at this time. The comprehensive services being provided have been delivered in accordance with an individual treatment plan.  They address not only his addictive illness, but his anxiety and depression as well.  Further, the services remain reasonably expected and medically necessary to improve the patients condition and prevent a more serious episode of illness.  Considering the clinical presentation and perusal of the peer-reviewed literature, residential placement is a safe, appropriate disposition consistent with good medical practice. Accordingly, the services at issue were and are medically necessary for treatment of the patients behavioral health condition.  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 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 parent of an enrollee has requested insertion of a lumbar artificial intervertebral disc for the treatment of the enrollees medical condition. Findings: The physician reviewer found that the requested insertion of a lumbar artificial intervertebral disc at L5-S1 has not been established as medically necessary for treatment of this patients medical condition. There are currently inadequate data in the peer-reviewed literature to adequately assess the performance of total disc replacement. There is a lack of evidence that disc replacement reliably, reproducibly, and over long periods of time fulfills the three primary aims of clinical efficacy, continued motion, and few adjacent segment degenerative problems. Total disc replacement has been associated with a high rate of re-operations, and the potential side effects that may occur with longer follow-up have not been fully documented. Zigler and colleagues completes a randomized, prospective, multicenter study of ProDisc-L versus circumferential fusion for low back pain. This study identified a reasonable cohort, subscribed the sample in a short time period, and demonstrated minimal attrition. However, the study lacks sufficient detail for independent evaluation of the data to confirm or reject the authors conclusions. In this case, imaging showed degenerative changes at L5-S1, but the patient has scoliosis above this level. There is no indication for surgery in this clinical setting and the patient is unlikely to benefit in the long-term. Given the lack of evidence in the peer-reviewed literature supporting insertion of a lumbar artificial intervertebral disc at L5-S1, 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90/400 mg for treatment of the enrollees medical condition. 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. In addition, the guidelines define acute hepatitis C as presenting within six months of the exposure with new rise in alanine aminotransferase (ALT) without alternative cause or low or fluctuating hepatitis C RNA values, which are not reported in this case. Even in suspected acute hepatitis C, the guidelines state that the provider and patient may elect to treat or to delay treatment initiation. Per 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 eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is 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 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.