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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for mental health and substance abuse residential treatment center level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patients use of opiates, benzodiazepines and cannabinoids was impairing his daily routine and contributing to significant impairment across multiple domains of functionality.  He had strained family relations. The patient was prescribed psychotropic medication for his psychiatric comorbidities of panic disorder and major depressive disorder. Based on the records, the patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting, after just three days of residential programming. The patient was experiencing sequelae from a medication, quetiapine, and treatment ambivalence. The patients poor motivation and disruptiveness prompted a behavior contract.  The patient was addressing family dynamics and boundaries in therapy, and looking for a sponsor. The patient was experiencing post-acute withdrawal symptoms and cravings to use. Thereafter, the patient showed steady signs of improvement.  He had a sponsor and was medication adherent. The records noted that he was making significant progress and developing better insight.  He was sleeping through the night and he realized that he needed to stay connected to the 12 steps.  He was considering a sober living environment. His family was not participating in family week, and he did not attend his second process group that day. Based on the medical documentation, discharge earlier would have been reasonable. Substance abuse residential treatment center level of care services provided a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. Final Result: The reviewer determined that a portion of the services at issue was 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: The parent of an enrollee has requested authorization and coverage for Saizen 8.8 mg vial for treatment of the enrollees growth hormone deficiency. Findings:  The physician reviewer found that the request for Saizen 8.8 mg vial is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has had a good response to GH therapy and has had no adverse reactions to Saizen. The patient experienced an allergic reaction to Nutropin, so brand name Saizen is medically necessary for treatment of the patients GH deficiency. The patients epiphyses remain open so continued treatment until epiphyseal fusion is clinically indicated. As such, the request for Saizen 8.8 mg vial has been established as medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 for 12 weeks for treatment of the enrollees hepatitis C virus. 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, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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: An enrollee has requested authorization and coverage for Vosevi 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. This applies regardless of fibrosis stage. The guidelines recommend that cirrhotic or non-cirrhotic genotype 1a patients who have failed a nonstructural protein 5A (NS5A) inhibitor should be treated with regimens including Vosevi for 12 weeks. These guideline recommendations are based on the clinical trial results showing a 96% cure rate in genotype 1a patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 authorization and coverage for Epclusa 400/100 mg tablets for 12 weeks. 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, which showed a 99% cure rate and superiority to Sovaldi with ribavirin . Delay in treatment may result in decreased survival. For these reasons, Epclusa 400/100 mg tablets 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:The parent of an enrollee has requested authorization and coverage for the medication Nasonex.  Findings:  The physician reviewer found that the physician reviewer found the submitted documentation supports the medical necessity of the requested medication. Allergic rhinitis is an inflammatory disease of the nasal mucosa, characterized by nasal congestion, runny nose, and itchy nose. It may be part of the atopic triad, with eczema and asthma. Children with allergic rhinitis may also have conjunctivitis, sinusitis, otitis media, and large tonsils and adenoids. Previously categorized as seasonal versus perennial, it is now categorized similar to asthma as intermittent versus persistent. For those children with impaired sleep, impaired daily activities, difficulties at school or work, and troublesome symptoms, the disease is considered moderate-severe. Treatments include systemic antihistamines, inhaled corticosteroids, and immunotherapy. In this patients case, the records document moderate-severe persistent allergic rhinitis complicated by stenosis of the nasal cavity, and upper airway obstruction which requires bilevel positive airway pressure despite tonsillectomy and adenoidectomy. He is undergoing immunotherapy, and is tolerating the treatment. He also takes daily cetirizine. Despite these therapies, he continues to have nasal congestion refractory to two different inhaled nasal corticosteroids. The only inhaled nasal steroid he has responded well to is Nasonex. Based on the complexity and severity of his illness, Nasonex is medically indicated and appropriate. All told, the requested medication Nasonex 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 pediatrics 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 dalfampridine 10 mg tablets extended release 12 hours (Ampyra) for treatment of the enrollees relapsing remitting multiple sclerosis.  Findings:  The physician reviewer found that the medical literature supports the requested medication in this clinical setting. Ampyra is considered a standard therapy for treatment of patients with MS and its efficacy is supported by medical evidence. Additionally, Ampyra is a U.S. Food and Drug Administration approved therapy for patients with MS. In this case, the patient had been prescribed the medication and had a favorable response. After halting Ampyra, the patient subsequently had a decline in her walking which affected her activities of daily living. As such, the documentation as well as the medical evidence support the benefits of this medication for this patient with MS. Accordingly, dalfampridine 10 mg tablets extended release 12 hours (Ampyra) 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested reimbursement for the Oncotype Prostate DX genetic testing for evaluation of the enrollees prostate cancer.  Findings:  Two physician reviewers found that several tissue-based molecular assays have been developed in an effort to improve decision making in newly diagnosed patients considering active surveillance and in treated patients considering adjuvant therapy or treatment for recurrence. Patients with clinically localized disease may consider the use of tumor-based molecular assays. Retrospective case cohort studies have shown that molecular assays performed on biopsy or prostatectomy specimens provide prognostic information independent of National Comprehensive Cancer Network (NCCN) risk groups. The NCCN guidelines recommend Oncotype Prostate DX post-biopsy for very low and low risk prostate cancer at diagnosis with 10-20 years life expectancy. This patient meets these criteria. For these reasons, the Oncotype Prostate DX genetic test was likely to be more beneficial for evaluation of this patients prostate cancer than available standard therapy. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition. Therefore, the health plan denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for services which include all of the specialists coming together as a group at the conclusion of the evaluations and/or diagnostic studies to formulate a diagnosis and treatment plan for treatment of osteoporosis and visual disturbance. Findings:  The physician reviewer found that in this case, the patient has multiple medical problems that are overall well-controlled.  He has access to multiple specialists, and his healthcare has been managed by his primary care physician with nursing and patient experience manager assistance. The documentation indicates there is good communication between the specialists and the primary care provider. The patient has been to multiple specialists, has had quick follow-up with his primary care provider after emergency department visit, and has had adequate advanced imaging with brain MRI/MRA.  His diabetes is well-controlled, his cholesterol panel is at goal and well-controlled, and his osteoporosis is stable.  He has a diagnosis of non-alcoholic fatty liver disease, which is common in patients with metabolic syndrome. His liver enzymes are normal, and he has had an appropriate diagnostic work-up for his liver condition. The patients main complaint is blurred vision. According to the submitted documentation, the patient has adequate care coordination in the current health system that he participates in. There is no documentation to suggest that a meeting where all the specialists discuss his care would change his current treatment or condition.  Additional specialist review with consultation at the Mayo Clinic for a second opinion and then services which include all of the specialists coming together as a group at the conclusion of the evaluations and/or diagnostic studies to formulate a diagnosis and treatment plan are not medically necessary 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services.  Findings:  The physician reviewer found that the patient experienced the sudden onset of severe lower back pain radiating to the left leg on the date of dispute On this date the patient was evaluated in the emergency department and discharged. The pain continued to be severe despite taking the prescribed medications. The patient had been instructed to return if symptoms worsened or failed to improve. The patient returned to the emergency department two days later. At that time the patient received imaging studies to rule out a spinal fracture and leg deep vein thrombosis. These entities can be life- or limb-threatening . As such, the services provided on met criteria for emergency medical services. However, the patient did not receive emergency medical services.  The patient returned to the emergency department for additional pain control. The patient had not suffered trauma. The patient denied any symptoms of acute infectious process such as fever. The patient denied any symptoms of spinal cord compression or cauda equina syndrome such as limb numbness or weakness, or bowel or bladder dysfunction. For the reasons provided, the medical services provided on other dates  were not emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on a portion of the dates of service at issue. Therefore, the Health Plans denial should be partially 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy (CPT code H2019) for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that the request for 40 hours per week of direct ABA therapy (CPT code H2019) was and is medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient demonstrates significant maladaptive behaviors that include taking clothes off in public, tantrums, self-harm, elopement, motor stereotypy, visual stereotypy, self-touch and poor self-awareness. The patient continues to require a high level of support to transition appropriately. Failure to master these skills places the patient at an increased risk for injury. In addition, the Behavior Analyst Certification Board indicates that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 tonsillectomy and adenoidectomy for treatment of enlarged tonsils. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. Per the records, this patients history of tonsil problems is not related to infection, but rather is related to tonsil enlargement resulting in airway compromise with snoring, nocturnal awakening and choking. Although the patient has a history of tonsil hypertrophy, there is no report submitted of evidence of sleep apnea documented on a sleep study. Given the absence of objective data showing sleep disorder, the medical necessity of the requested services has not been established. All told, the requested tonsillectomy and adenoidectomy are not medically necessary 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 otolaryngology 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.