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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for group 3 power wheelchair K0856 for treatment of the enrollee who has a history of polio (non-ambulatory).Findings:  The physician reviewer found that The records do not establish that the patients mobility related activities of daily living could not be met with a group 2 power wheelchair. The patient in this case is able to stand to urinate, perform weight shifts to prevent pressure ulcers and propel a manual wheelchair for shorter distances.  Group 2 wheelchairs are otherwise distinguished versus higher performance group 3 wheelchairs in the following areas: group 2 power wheelchairs can overcome obstacles of 40 mm in height (60 mm for group 3); group 2 power wheelchairs have a minimum top end speed of three miles per hour (4.5 mph for group 3); group 2 power wheelchairs have a range of seven miles (12 miles for group 3); and group 2 power wheelchairs are dynamically stable at up to six degrees (7.5 degrees for group 3). There are subdivisions within each respective group for various weight capacities including extra heavy group 2 power wheelchairs for patients whose weights exceed 600 pounds. Power wheelchairs are not designed or meant to carry large amounts of personal property, which would negatively alter its stability by increasing the height of the center of gravity. American with Disabilities Act compliant ramps must have a slope of no less than 12 units run for one unit rise (4.76 degrees), which is within the minimum capacity of a group 2 power wheelchair (Americans with Disabilities Act). This group of wheelchairs is reserved for persons with severe impairments. Typical conditions for which this group of wheelchairs are prescribed appropriately include amyotrophic lateral sclerosis, stroke with hemiplegia, spinal cord injury with tetraplegia, cerebral palsy, muscular dystrophy, advanced Parkinsons, and advanced multiple sclerosis.  Therefore, according to the documentation submitted, group 3 wheelchair K0856 is not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 rituximab 1000 mg on Day 1 and Day 15 and then every four months for treatment of the enrollees microscopic polyangiitis.  Findings:  The physician reviewer found that the request for rituximab 1000 mg on Day 1 and Day 15 and then every four months is not medically necessary for treatment of the patients medical condition. According to the medical records provided for review, there is a lack of documentation demonstrating a clinical rationale or evidence for the request for rituximab. There are a lack of peer-reviewed evidenced based guidelines that support every dosing every four months of rituximab for the treatment of microscopic polyangiitis. Based on the documentation provided for review and lack of support in the peer-reviewed literature, the request for rituximab 1000 mg on Day 1 and Day 15 and then every four months is not 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Rituxan for treatment of the enrollees seropositive rheumatoid arthritis.Findings:  The physician reviewer found that For the treatment of rheumatoid arthritis, the 2015 American College of Rheumatology (ACR) guidelinerecommends methotrexate (MTX) with or without tumor necrosis factor inhibitor (TNFi) as the next treatment option in patients who have failed MTX alone.  A second TNFi with or without MTX of non-tumor necrosis factor biologic with or without agent is recommended over Xeljanz. There are also multiple studies demonstrating efficacy and safety with TNFi over the years in treating moderate to severe RA.  TNFi therapy has superior efficacy when used in combination with MTX, based on high quality evidence. There is evidence that a second TNFi is effective in those who have tried and failed a previous TNFi or have had adverse reactions to other TNFi.  Smolen and colleagues noted the following, Golimumab reduced the signs and symptoms of rheumatoid arthritis in patients with active disease who had previously received one or more TNF alpha inhibitors.  There are very limited studies that are looking at the failure of first TNFi agent and a different biologic agent.  In this case, the patient has both active seropositive RA and active MG. The documentation shows that this patient has tried and responded to Enbrel but stopped due to worsening alopecia. The records note previous use of methotrexate, but the records do not indicate as to why this was stopped. There is a lack of large randomized controlled trial looking at the use of Rituxan and MG.  There are case reports showing improvement in MG patients and tolerability, but larger studies are needed. The medical literature do not show that TNFi is contraindicated in MG. As such, the medical records fail to demonstrate the medical necessity of Rituxan in this patients case. Therefore, Rituxan is not medically necessary for the treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested reimbursement for the prothrombin G20210A (Factor II) mutation testing and methylenetetrahydrofolate reductase (MTHFR) mutation testing for evaluation of the enrollees recurrent pregnancy losses. Findings:  The physician reviewer found that while meta-analyses and a retrospective cohort study have revealed an association between inherited thrombophilias and first-trimester pregnancy loss, prospective cohort studies have found no association between inherited thrombophilias and fetal loss. Therefore, the prothrombin G20210A (Factor II) testing was not indicated in this patient. Homozygosity for the MTHFR gene mutations is the most common cause of hyperhomocysteinemia, but MTHFR mutations alone do not appear to convey an increased risk for venous thromboembolism or pregnancy complications. Thus, the testing for MTHFR was also not medically indicated in this patient. Given these findings, the prothrombin G20210A (Factor II) mutation testing and MTHFR mutation testing performed were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation 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 obstetrics and gynecology 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 obstetrics and gynecology 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 authorization and coverage for Praluent Pen 75 mg for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that the physician reviewer found that the patient has documented obstructive coronary disease, severely elevated LDL cholesterol and intolerance to both multiple statin medications and Vytorin. In this circumstance, treatment with a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor is medically appropriate. Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria. In this setting, PCSK9 inhibitors have been shown to be safe and effective, with improved cardiac outcomes in prospective randomized trials. Therefore, Praluent Pen 75 mg is medically necessary for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for intensity modulated radiation therapy (IMRTfor treatment of the enrollees uterine cancer. .Findings:  Three physician reviewers found that upon review of available data, IMRT is likely more beneficial in treating this patients endometrial cancer than standard therapy consisting of three-dimensional conformal radiotherapy (3DCRT). Chen and colleagues reported that the main areas where IMRT benefits patients is decreased gastrointestinal toxicity and decreased marrow toxicity. For marrow toxicity, a multi-institutional phase II trial showed that bone marrow toxicity could be decreased with the appropriate IMRT planning parameters (Klopp, et al). Based on this support, the requested IMRT has a substantial advantage over 3DCRT in the treatment of endometrial cancer. Further, based on the improved side effect profile and potential impact on the patients ability to undergo full-dose chemotherapy, IMRT should be considered standard therapy versus 3DCRT. Accordingly, IMRT is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service 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: Physician reviewer number one is board certified in radiation oncology 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 radiation oncology 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 radiation oncology 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 patient has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. Findings:  The physician reviewer found that According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier for 12 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 authorization and coverage for bilateral sacroiliac (SI) joint injections for treatment of the enrollees SI joint dysfunction.  Findings:  The physician reviewer found that The request for bilateral SI joint injections are medically necessary for treatment of the patients medical condition. SI joint injections are an appropriate, evidence-based treatment option for low back pain of sacroiliac origin and are standard of care for the treatment of this condition. The physical examination supports the diagnosis of SI joint dysfunction. In addition, the patient has not responded to conservative care. The presence of neural compression does not indicate that the patient lacks SI joint pathology. The patient has both lumbar radicular pain secondary to neural compression and lumbar axial pain secondary to sacroiliac joint pathology. Therefore, the requested services have been established as medically necessary for the 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 board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg for eight weeks for treatment of the enrollees hepatitis C. 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, and advanced fibrosis is not required for treatment. Per the guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Harvoni 90-400 mg for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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: The patient has requested reimbursement for the inpatient behavioral health level of care services for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that This patient had a formidable psychiatric history characterized by affective illness, anxiety with somatic features, cognitive decline and substance use. Upon presentation, she was anxious, disorganized and unable to attend to her activities of daily living. She had history of non-adherence with treatment and a recent acute hospitalization. As such, treatment in a less restrictive setting at the time would have been inadequate while hospital-based care was reasonably expected to improve the patients condition and prevent a more serious condition. Further, the admission served the purpose of refining the patients diagnostic assessment. However, based on the medical records, the services at the acute inpatient setting were no longer necessary . The patients mood stabilizer was changed from aripiprazole to olanzapine and she was continued on sertraline and gabapentin for mood and anxiety. Trazodone for sleep was discontinued but reinstated a few days later. The patient was anxious in both mood and affect. However, she had no suicidal ideation or hallucinations. Her intellect and memory were normal. She was eating meals and sleeping well. She was not disruptive on the unit. The diagnostic assessment was generalized anxiety disorder.  The patients diagnosis was changed to bipolar disorder. She was adherent with her medications which had not been changed since admission. She slept seven hours at night, and her mood remained anxious but her affect was brighter.  The patient made good eye contact, she was interacting with peers, and she was not confused. She was actively engaged in treatment. She had a supportive sister and male friend. Although ongoing care was indicated, there was no evidence of an acute psychiatric syndrome or that service delivery in a less restrictive setting would have been unsafe or inadequate. As such, inpatient behavioral health level of care services were medically necessary but not thereafter. 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 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 Epclusa 400-100 mg for 12 weeks for treatment of the enrollees hepatitis C.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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Epclusa for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, Epclusa 400-100 mg for 12 weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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.