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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a neurology consultation. Findings:  The physician reviewer found that the records provided for review document that this patient has a chronic medical condition and is frustrated with her level of pain. Despite being treated with multiple medications, the patient continues to have severe pain including worsening pelvic floor pain. In light of the patients chronic condition, the patient should be evaluated by a neurologist. Furthermore, seeking additional medical care or another opinion for the patients worsening pain is indicated given her lack of adequate pain management at this time. Thus, the requested neurology consultation is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested referral 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 internal medicine with sub-specialty certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for ongoing refills of Truvada without being evaluated by a Plan Provider for treatment of the enrollees human immunodeficiency virus (HIV) pre-exposure prophylaxis. Findings:  The physician reviewer found that pre-exposure prophylaxis is a very effective part of HIV prevention in high-risk patients. Moreover, pre-exposure prophylaxis does require routine laboratory monitoring and physician evaluation in order to insure safety and continued need.  Truvada is associated with renal toxicity and bone density issues. Without routine evaluations it is not safe to continue to prescribe Truvada. For that reason, Truvada should be continued with follow-up by a physician. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a positron emission tomography (PET) scan for evaluation of the enrollees lung nodule. Findings: Two of the three physician reviewers found that this patient presented with an incidental finding of a pulmonary nodule. He was then evaluated appropriately, first with a routine CT scan to confirm the presence of the nodule.  At that point, a decision was needed concerning how to further evaluate the nodule. The Society of Thoracic Imaging and Diagnosis, otherwise known as the Fleischner Society, is a well-known organization that has established guidelines for the evaluation of incidentally detected pulmonary nodules. For incidentally detected nodules that are greater than 8 mm, the Fleischner Society guidelines call for either a follow-up CT scan in three months, and/or a PET/CT, and/or a biopsy.  This patient was previously evaluated with a PET/CT which was not suggestive for tumor.  Ultimately, he did have a biopsy, which was also negative. Upon review of the patients history, he does have a potential reason to have this nodule with stranding to the pleura, as he had a prior thoracotomy and pleurodesis procedure.  The current medical evidence does not support the requested services in this clinical setting.  At this point, a follow-up CT scan should be sufficient. Final Result: The reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for transcatheter arterial chemoembolization (TACE) for treatment of the enrollees metastatic adenocarcinoma to the liver. Findings: Two of the three physician reviewers found that the patient is diagnosed with oligometastatic adenocarcinoma of the liver in segment 7. She has undergone multiple rounds of chemotherapy in the past which have prevented growth of the lesions, but have not eradicated them. Magnetic resonance imaging performed and confirmed hepatic metastases. Office notes indicate this patient has excellent performance status. In addition, this patient is not being considered for liver transplantation at this time. The provider recommended transcatheter arterial chemoembolization (TACE) for treatment of this patient's hepatic metastases. The Health Plan denied the requested services as investigational. There is a lack of peer-reviewed literature that supports the use of TACE in this particular clinical situation. The documentation submitted does not indicate that she meets the criteria for treatment with TACE. She does not have the specific tumor types that would be covered by TACE. She is not being considered for liver transplantation that may have involved the use of TACE as a bridge. She does not have bulk symptoms for the liver metastases. Instead, other options are available to her for treatment of her tumors. Final Result: The 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: Reviewers 1 and 3 are board certified in diagnostic radiology with sub-specialty certification in interventional radiology and are actively practicing. Reviewer 2 is board certified in diagnostic radiology with expertise in interventional 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 authorization and coverage for 60 x 6 mg/0.5 ml sumatriptan injections per month for the treatment of the enrollees severe cluster headaches. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication quantity. This patient has had trials of several different medications reasonably expected to improve headache frequency and severity for the diagnosis of chronic cluster headaches, with thus far unremarkable results. The patients provider correctly noted that that sumatriptan can be safely used on a daily basis for the treatment of chronic cluster headaches.  Per the records, this has been the only effective treatment for this patient.  There are no safety concerns regarding this treatment based on literature review. The medical evidence supports the requested medication quantity in this setting. Final Results: The reviewer determined that the requested medication quantity 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollee's medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment provided for 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 was experiencing mild post-acute withdrawal symptoms.  He was not a danger to himself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable.  He was motivated and appeared to be working the program. He had a sponsor.  He was cooperative and participating in his treatment plan.  No new problems had arisen.  Although he continued to struggle with his emotions and required further treatment to help develop coping skills, he could have been stepped down to an ambulatory level of care, such as intensive outpatient program level of care, and pursued further psychological support as well as relapse prevention and education. Final Result: The reviewers 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 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, one tablet daily for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the blood test for evaluation of the enrollees ankylosing spondylitis. Findings: All three physician reviewers found that measurement of serum concentrations of tumor necrosis factor (TNF) antagonist drugs and antibodies to TNF antagonist drugs is not supported for routine use in the current peer-reviewed medical literature. This patient is currently being treated with Remicade and is described as generally stable. It is not considered standard of care per current peer-reviewed guidelines given the paucity of peer-reviewed medical literature to support this type of testing for the management of ankylosing spondylitis. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in rheumatology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a wearable cardioverter defibrillator for treatment of the enrollees left bundle branch block with an ejection fraction (EF) in the range of 25%. Findings:  Two out of three physician reviewrs found that the role of the implantable cardioverter defibrillator (ICD) in patients with significant left ventricle dysfunction is well documented. Similarly, the wearable cardioverter defibrillator has been shown to be an appropriate strategy in subsets of patients awaiting permanent ICD placement. However, this patient does not meet the criteria for ICD placement since she does not present with high risk factors for sudden cardiac death such as severe ambient ventricular arrhythmias, recurrent syncope, or advanced heart failure. Final Result: The reviewers determined that the requested wearable cardioverter defibrillator is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Reviewers number 1 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. Reviewer 2 is board certified in internal medicine with sub-specialty certification interventional cardiology and is 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 magnetic resonance imaging (MRI) of the thoracic spine and lumbar spine for evaluation of the enrollees back pain. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  The primary reason to obtain an imaging study is if it will alter the course or type of therapy.  With regards to the thoracic spine, the patient has already had one MRI which demonstrated thoracic spondylosis. At this time, he has no significant localizing symptoms other than pain, which the referring practitioner related to muscle pain.  He has no neuropathies, his strength is good, and the physical examination was essentially negative.  Thus, the requested MRI of the thoracic spine is not medically necessary for the evaluation of this patient. In terms of the lumbar spine, the patient is having continued symptoms after surgery.  The American College of Radiology has established appropriateness criteria for several clinical presentations. One of these published lists of criteria describes the appropriateness of studies to evaluate low back pain. For patients with low back pain or radiculopathy and new or progressing symptoms or clinical findings with history of prior lumbar surgery, an MRI is usually appropriate per the criteria.  This patient has had a reasonable trial of conservative management.  It is possible that a lumbar MRI would make a difference in his management.  Following surgery, patients will occasionally develop postoperative seromas, infection (unlikely in this patient), scar formation, or retained bony fragments.  Thus, the requested MRI of the lumbar spine is medically necessary for the evaluation of this patient. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment services provided for treatment of the enrollees alcohol dependence and severe depression. Findings:  The physician reviewer found that the records document that this patient had mild post-acute withdrawals of anxiety and insomnia. He was not a danger to himself or others and there were no emotional, behavioral, cognitive, or impulsive symptoms to warrant further residential services. His hypertension was controlled with medications and psychiatrically he could have been managed at a lower level of care. He was motivated and engaged in treatment, his cravings were at a minimum and he had sober supports in place including friends in Alcoholics Anonymous. His recovery could have continued an ambulatory basis in a less restrictive treatment setting. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for FoundationOne gene testing. Findings:  The physician reviewer found that FoundationOne is a molecular assay that explores the mutations of an individuals cancer cells.  At this time, there is a lack of convincing evidence that the assay adds to our decision making ability, or yields a result that is reliably clinically beneficial.  There are a variety of non-randomized studies exploring the value of molecular profiling.   A study noted this ongoing research as well as the serious limitations of such studies. A randomized trial did not demonstrate significant clinical benefit from choosing therapy based on molecular targets versus by the oncologists clinical judgment.  Finding the presence of a mutation does not guarantee that a treatment directed at this mutation will produce a clinically beneficial response.  In sum, FoundationOne gene testing performed  was not likely to be of greater benefit than other methods of evaluating this patient.  Final Result: The reviewers 2 of 3  determined that the services at issue were 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 reviewers 1, 2 & 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for physical therapy. Findings:  The physician reviewer found that The physical therapy provided was not and is not necessary for treatment of an emergency medical condition. Physical therapy evaluation and treatment for a humerus fracture is a rehabilitative process, one of restoring function over weeks or months. A study compared rehabilitation that began on the second postoperative day to rehabilitation that began weeks after surgery. Their study showed a benefit to intervention that began on the second postoperative day. An intervention beginning on a time scale of days to weeks after surgery cannot be considered emergency medical treatment. In the patients case, physical therapy services are indicated for treatment of her impaired function after humerus fracture, however physical therapy services do not constitute emergency medical services. Therefore, the services at issue were not and are not necessary for treatment of an emergency medical condition. Thus, the patient did not receive emergency medical services on the dates of service at issue.  Final Result: The reviewers determined that the patient did not receive emergency medical services on the dates of service at issue. Credentials/Qualifications: Physician reviewer is board certified in physical medicine with sub-specialty certification in neuromuscular 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.