Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson. Upon review of the submitted medical records, the patient presented with severe pain and concerns that her pain was due to a problem with her spine and prior surgical repair. She was advised by her treating provider to go the ER. Aside from the pain, disruption or loosening of the vertebral hardware, spondylolishtesis of vertebrae, and synthetic discs could have caused a compressive neuropathy which may have caused distal muscle weakness, bladder and bowel dysfunction, and permanent disability.  There were also other possible etiologies of the back pain and headache including infection.  The ER visit was the appropriate venue for evaluation because of the level of evaluation required. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition that required immediate medical attention. Thus, the services meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities.  Digital breast tomosynthesis with [three-dimensional] 3D images might overcome some of the limitations of conventional [two-dimensional] 2D mammography for detection of breast cancer. Researchers investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. It was concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. As such, the digital breast tomosynthesis was likely to be more beneficial for breast cancer screening than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation 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 diagnostic radiology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the Molecular Marker Test Afirma Gene Expression Test for evaluation of her medical condition.  In this case, the Afirma test is clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  In addition, benign results reassure the patient and provider that the chances of cancer in the nodule are less than 5%. Without the Afirma test, the chances are 10-20% so most providers would suggest surgery in that case.  Even if surgery is still done due to the size of the nodule, a less extensive surgery can be done such as a lobectomy versus thyroidectomy if the nodule were cancerous.Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and 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 endocrinology and metabolism 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 partial hospitalization program treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In this particular case, the treatment team who knows this patient best recommends continued treatment at the partial hospital level of care out of concern that the patient does not command the skills needed to maintain weight and function with full autonomy in the outpatient setting. This represents a critical variable in the placement determination process. The treating team justifies their determination within the context of partial hospital level of care guidelines as developed by the American Psychiatric Association. Factors that warrant partial placement based on the assessment include patient status and environmental support, psychiatric comorbidity, preoccupation with intrusive repetitive thoughts, and the need for structure to help with weight management and dietary habits. The patient has not consolidated the treatment gains necessary to maintain a healthy weight, and is at risk for undue morbidity and admission to a higher level of care in the absence of partial hospitalization. The services at issue are safe, appropriate and consistent with good medical practice. Thus, the partial hospitalization program treatment services in dispute 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 residential treatment center services 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 had received residential treatment services after a separate stay at a different residential treatment center.  He was not suicidal, and he was not homicidal.  He was cooperative, actively participated and was engaged in his therapies and groups.  He was learning how to express his feelings rather than act upon them, and to communicate in a more effective, controlled, and respectful manner with peers and authority figures.  His medications were still being adjusted, but this was not of a complexity that required a residential setting.   His concurrent medical condition did not require a residential setting.  His family setting would not have undermined treatment at a lower level of care, as his family was actively involved in the process with him.  Although he still required individual and family therapy, this could have been continued at a lower level of care.  He no longer required 24-hour supervision on a nursing and medical basis.  All told, residential treatment center services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that PHP treatment is medically necessary in this clinical setting. Based on the documentation submitted for review, the patient has a very severe case of school refusal with diagnosed generalized anxiety disorder. Her re-introduction to school has started, but is going fairly slowly. She is extremely anxious and becomes very agitated when the subject is discussed. The technique the treatment team is using, exposure and response prevention, can be effective for this condition.  It also can take a lot of time and patience on the part of the staff and patient to successfully implement such a program. Therefore, treatment at the PHP level of care is medically necessary, as it is likely she would relapse if she were transitioned to a lower level of care at this time.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an eight-week course of Harvoni for treatment of her 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 and the Infectious Diseases Society of America, 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, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight weeks. 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.  For these reasons, the requested eight-week course of Harvoni 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, patients with diabetes are at risk for fast progression of fibrosis. Guidelines recommend treatment-naive genotype 1 patients be treated with Harvoni for 12 weeks. 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. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. However, Harvoni for eight weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks. Thus, Harvoni for eight weeks in treatment-naive patients without cirrhosis who have a baseline HCV viral level of less than six million IU/mL is indicated based on post-hoc analysis of the clinical data from ION-3 trial. In sum, the medical necessity for Harvoni for 12 weeks has not been established in this clinical setting.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the upper extremity (CPT 73221) for evaluation of her medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Wrist abnormalities are less commonly evaluated, but that is due to the lesser frequency of wrist abnormalities that are amenable for surgical cure. In this case, the MRI of the upper extremity was clinically indicated as it allowed the provider to define ligamentous or tendon abnormalities. As discussed in the medical literature, MR imaging is a powerful method for evaluating acute and chronic lesions of the stabilizing articular elements (volar plate and collateral ligaments) of the fingers and thumbs, particularly in the frequently affected proximal interphalangeal and metacarpophalangeal joints. Furthermore, the medical literature states Magnetic resonance imaging represents a relevant way to diagnostically assess the wrist with high-resolution, multiplanar imaging without employing ionizing radiation. It influences clinical and surgical diagnosis and management of wrist pathologies.  In conclusion, the MRI of the upper extremity (CPT 73221) was medically necessary as it provided the information necessary to make a surgical decision.  Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested continuous positive airway pressure (CPAP) supplies 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 use of home, unattended, sleep studies does not contribute to the management of patients.  Even if the apnea-hypopnea index (AHI) reported is correct, there is no data on the position of sleep.  Thus, in this case, positional obstructive sleep apnea is not ruled out.  The use of CPAP may not be indicated for patients with positional obstructive sleep apnea.  In order to demonstrate the need for CPAP and supplies, a facility-based sleep study with a certified attendant must document that the patient met criteria for the medical necessity of treatment with CPAP and the optimal setting of CPAP used.  Based on the documentation provided for review, the equipment at issue was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the equipment at issue was not and 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 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 transcranial magnetic stimulation for treatment of her major depressive disorder.   Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  The peer-reviewed medical literature does not support a contraindication for the use of transcranial magnetic stimulation in a depressed individual with a co-occurring diagnosis of posttraumatic stress disorder.  Considering the medical records and expanding peer-reviewed literature base, transcranial magnetic stimulation was a safe and appropriate treatment consistent with good medical practice.  The services at issue were reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, transcranial magnetic stimulation was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Harvoni for treatment of his 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 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 for 12 weeks.  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.  All told, Harvoni for 12 weeks is medically indicated 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 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.