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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus infection genotype 3.  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 patient should be considered treatment-naive because he did not fail any appropriate or recommended therapies for hepatitis C patients with genotype 3. This patient is interferon-eligible as no medical contraindication is reported. Although the provider reports that there is concern about PEG-interferon side effects, the AASLD/IDSA recommendations were created with full knowledge of those effects, and the AASLD/IDSA specifies medical contraindications to PEG-interferon which are not reported in this case. If the patient is considered a Sovaldi/ribavirin failure rather than treatment-naive, Sovaldi/PEG-interferon and ribavirin are preferred over Daklinza regimens in interferon-eligible patients. All told, the requested treatment with Sovaldi and Daklinza is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result:  The reviewer determined that the requested medications 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 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 residential treatment center (RTC) services for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patients record shows that the patient was not a danger to herself or to others and she was not violent. Furthermore, there was no level of substance abuse that imminently endangered the patient and her substance abuse problem was not a significant focus of this patients treatment. The patient was able to physically care for herself and she was cognitively intact. There was no evidence of emotional, cognitive, or behavioral dysregulation to a degree which required 24 hour care. The record further states that the patient and her family were working together in their therapies and her home environment was supportive. Although the patient continued to struggle with feelings of vulnerability, emotional dysregulation, and inadequate social skills, the patient was appropriate for continued treatment at a less intensive level of care. The records do not establish that stepping the patient down to a lower level of care would have resulted in significant deterioration of her condition. For the reasons stated above, the services at issue were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested botulinum toxin (Botox) injections for treatment of her medical condition.  Three physician reviewers found that based on the documentation submitted for review, the patient has had significant headache freedom from previous Botox injections. After her initial worsening, Botox was effective in treating the patients chronic headache disorder. There is a typical latency prior to the establishment of efficacy when Botox is used under these circumstances. Furthermore, there is data supporting efficacy of Botox used for chronic daily headache in the peer-reviewed literature cited above. In this case, botulinum toxin (Botox) injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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 neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lap-band revision surgery for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient does not meet criteria for repeat or revision bariatric surgery as the records do not document any present complication of the original bariatric procedure that requires surgical repair to correct.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lap-band revision surgery is not medically indicated for the treatment of this patient. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested complex open magnetic resonance (MR) guided piriformis resection, neuroplasty of the superior gluteal nerve, neuroplasty inferior gluteal nerve as well as neuroplasty of the sciatic nerve in the ischial tunnel, including decompression neuroplasty of the posterior femoral cutaneous nerve and inferior cluneal branches for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has chronic gluteal/pelvic pain.  However, before any surgery is recommended, all other sources of pain must be ruled out.  The submitted records do not document that this has been done in this case, since there is no documentation of hip imaging or urologic or gynecologic examinations/imaging.  Piriformis syndrome and surgery is considered controversial.  The examination by her surgeon was not definitive and rather vague.  Similarly, the other providers who have diagnosed piriformis syndrome have not performed a detailed examination, nor performed other confirmatory physical examinations.  There is a lack of support for the requested services in this patients case.  Therefore, the requested services are not likely to be of greater benefit than other treatment options. 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: All three reviewers are board certified in neurological surgery 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:   The parent of an enrollee has requested a residential treatment center that offers a long-term residential treatment program of up to 12-18 months in length for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the request for a residential treatment center that offers a long-term residential treatment program is medically necessary for this patient. The patient has a history of unstable, unpredictable and violent verbal and physically abusive behavior. She is unable to tolerate any degree of frustration, stress, or questioning of her behavior/conduct without aggressive behavior. She requires a highly structured setting to provide treatment and contain her explosive and unpredictable behavior, which is not only imminently dangerous to herself, but to her family and potentially the public. The patient needs to learn coping skills and distress tolerance, in an environment which provides a high level of containment and within which she will be able to practice these skills safely, for herself and others. Should the pattern of early termination of services continue, it is likely the patient may become a serious threat to the public.  Thus, 24-hour structured monitoring in a residential setting, for at least six months and in a residential treatment center that offers a long-term residential treatment program is medically necessary. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for treatment of her hepatitis C virus infection.  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 limited life expectancy due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi, PEG-interferon, and ribavirin for 12 weeks. This is based on the Boson trial, which showed cure rate of 95% in treatment-naive genotype 3 patients (Foster, et al).  The AASLD/IDSA guidelines specify contraindications to interferon in the following circumstances: hemoglobin below 10 g/dL, platelet count below 90 K/uL, decompensated cirrhosis, autoimmune hepatitis, uncontrolled depression, or existing cardiac disease. The Food and Drug Administration (FDA) approved prescribing information for PEG-interferon lists only decompensated cirrhosis, known allergy to PEG-interferon, and autoimmune hepatitis as contraindications. None of these are substantiated in the provided records. For these reasons, although treatment of hepatitis C is warranted in this case, there is no literature to support an exception for the use of Sovaldi and Daklinza for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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 bariatric surgery consultation and follow-up visits for treatment of his medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. The patient has been working with a nutritionist and has provided documentation of at least three consecutive monthly visits with his primary care physician for ongoing weight management. Referral to a bariatric surgeon has also been recommended by the nutritionist. The patient has also obtained cardiology clearance in preparation for surgical evaluation. It is medically necessary for this patient to be evaluated by a bariatric surgeon and multidisciplinary team. For the reasons stated, bariatric surgery consultation and follow-up visits are medically necessary in this clinical setting. 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 general surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a nutritional drink supplement for treatment of her medical condition.  Findings: The physician reviewer found that the documentation indicates that this patient is not having any problems with swallowing or nausea with vomiting. She complains of feeling a loss of appetite when starting a meal. The history of a patient with unintentional weight loss includes documenting the weight loss, assessing the pattern of weight loss, evaluating for eating disorders and possible intentional weight loss, and eliciting other factors that may be related to the weight loss. In this case, the documentation does not support that the patient has had significant weight loss. Her BMI is within normal limits for her height. She does not have a medical condition that would cause any mechanical difficulty with eating. All told, the requested nutritional drink supplement is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested nutritional drink is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested cetirizine for treatment of her medical condition.  Findings: The physician reviewer found that the patient is requesting antihistamine cetirizine for the prevention of severe allergic reaction with exposure to latex containing products such as latex balloons. However, a review of medical literature has shown that preventive pharmacotherapy for this indication is rarely effective. The most effective method is avoidance. The use of antihistamines such as cetirizine is only indicated for the treatment of active symptoms. The progress note dated does not provide acute or chronic active latex allergy symptoms. The submitted documentation also does not indicate the patient has had previous trials with other antihistamines and their outcomes to support the medical necessity for the requested medication. All told, the requested medication 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 subspecialty certification in allergy and immunology 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 total right hip replacement surgery for treatment of his medical condition.   Findings: The physician reviewer found that there is documentation of moderate to severe right hip osteoarthritis. Conservative treatment has been limited to medications and activity modification. There is no documentation of participation in the recommended weight loss program or exercise therapy. There is no documentation of response to recent steroid injection. In addition, the peer reviewed literature supports the conclusion that morbid obesity (body mass index greater than 40) confers increased risk for complications and poorer outcomes in total joint arthroplasty, including prosthetic joint infections. In the absence of a trial of weight management combined with physical therapy and/or steroid injections the requested surgery is not indicated. Therefore, total hip replacement surgery is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested treatment in a comprehensive cancer treatment center for treatment of her medical condition.   Findings: The physician reviewer found that the patient presents with an aggressive and rare cancer and was appropriately evaluated and treated at a large cancer center that has extensive experience in interdisciplinary care. Special cancer centers with such experience are designated as such by the National Cancer Institute (NCI) in a highly competitive peer-reviewed process for treatment of patients with aggressive disease. All told, the records support the requested treatment in a comprehensive cancer treatment center as medically necessary in this patients case.  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 medical oncology and hematology 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 electroconvulsive therapy (ECT) and inpatient mental health treatment for treatment of his medical condition.  Findings: The physician reviewer found that considering the multiple evidence-based interventions provided in the outpatient setting, the patients recurrent depressive illness is best characterized as treatment resistant. ECT is recognized as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe mood disorders. Considering the affective impairment with lingering anxiety and suicidality, both the inpatient setting and ECT were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, 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: An enrollee has requested Gamma Knife surgery for treatment of her medical condition.  Findings: The physician reviewer found that stereotactic radiosurgery (SRS) implies the use of technologies which improve targeting accuracy, and allow for high dose, single fraction radiation delivery. Generally, a three-dimensional coordinate system is used to more accurately localize the target(s). CyberKnife is different than Gamma Knife. CyberKnife is a delivery system which allows for SRS, using real time monitoring of fiducials or bony anatomy, coupled with robotically controlled tracking of these fiducials. With CyberKnife, the patient is immobilized in a less rigid frameless system. There is no known clinical benefit of any SRS system over another. CyberKnife has the ability to treat patients without a neurosurgical frame, therefore CyberKnife surgery is the preferred procedure in this clinical setting. Accordingly, the request for Gamma Knife surgery has not been established as 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 physician reviewer 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.