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 Zepatier for 12 weeks for treatment of the enrollee's hepatitis C.Findings: The physician reviewer found according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier for 12 weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of residential treatment services, or in the alternative fewer consecutive days of residential treatment for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that The American Academy of Child and Adolescent Psychiatry (AACAP) recommends that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. In cases such as this, an evidence-based instrument such as the Child and Adolescent Level of Care utilization System (CALOCUS) is indispensable in determining necessary level of care for children and adolescents. In this patients case, she presents with a significant risk of harm (score 4) due to her cutting and passive suicidal ideation. The patients functional status is a serious issue (score 5), as she has had numerous disruptions in her home and school status due to her erratic behaviors including theft. The patient presents with no co-morbid conditions (score 1) with a prior history of substance abuse. The patients recovery environment is highly stressful (score 4) as the progress notes indicate that the patients home life is stressful. The patients recovery environment provides minimal support (score 4) as the patients primary caretakers are reported to have difficulty with emotional support in an inappropriate manner as referenced to by volatile family therapy sessions at the RTC. The patient has demonstrated negligible improvement in prior treatment (score 5) due to extremely minimal positive treatment response in the past at numerous different levels of care. The patients acceptance and engagement in treatment has been adversarial (score 4), as the patient has minimal insight into her treatment needs. The patients parents have been obstructive to treatment (score 3) as they appear to work with providers but have difficulty creating a definition of the problem. Overall, this gives her a composite score of 30, which correlates with a treatment in a hospital or secure RTC. Moreover, the patients presentation suggests risk rating scores in the range of 3. Given these findings, the requested 30 consecutive days of residential treatment services are supported as medically necessary for treatment of this patients behavioral health issues. 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 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 authorization and coverage for high-frequency chest wall oscillation air-pulse generator system for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this clinical setting. The patient has documented need for airway clearance as she has a history of cystic fibrosis (CF) with respiratory pathogens. The records noted that she has been diagnosed with CF as child and has failed therapy with inspiratory valves (Acapella) and manual chest percussion. There is evidence that the use of chest wall oscillation air-pulse generator systems benefit patients in CF patients which have been shown to include a lower incidence of pneumonias, hospitalizations, and intensive care unit days. The studies have noted that participants found it easier to breathe when using high-frequency chest wall oscillation air-pulse generator systems compared to other systems. Additionally, this patients previous system is greater than five years old and it has malfunctioned. The patient attends college and she requires a portable system. The requested equipment is medically indicated to prevent exacerbations of her medical condition. Therefore, based on the documentation provided, high-frequency chest wall oscillation air-pulse generator system is medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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 authorization and coverage for proton beam radiation therapy (CPT Codes 77523, 77525 and 77522) for treatment of the enrollees osteosarcoma. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested service. The patient presents with osteosarcoma that cannot be resected. Given the size of the tumor a high dose of radiation is needed in order to control the gross disease. In this case, proton beam radiation therapy can improve local control of the tumor while sparing the surrounding normal structures including the small bowel. The plan dose volume histogram provided for review illustrates this point. Proton beam radiation therapy in similar tumors such as chordoma or chondrosarcoma indicate that proton therapy is more beneficial than therapy with photon techniques. Based on these reasons, proton beam radiation therapy is medically necessary for treatment of the patients medical condition. All told, the request for proton beam radiation therapy (CPT Codes 77523, 77525 and 77522) has been established as medically necessary for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg/100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines do not require documentation of clinical risk factors to quality of treatment, recommending therapy in all patients regardless of factors such as alcohol use or intravenous drug use. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. In this case, documentation of negative NS5A resistance testing was submitted. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 anterior optical coherence tomography (OCT) (CPT 92132) for evaluation of the enrollees unspecified hereditary corneal dystrophies. In patients with anatomical narrow anterior chamber angles, the risk of an acute spontaneous angle-closure glaucoma attack increases with time, as the anterior chamber loses depth. Therefore, it is imperative to evaluate the structure of the angle and to determine if it is occluded. Anterior segment OCT allows a high-resolution, objective measurement of the angles structures without direct contact with the eye. However, the medical records provided for review fail to demonstrate anything relating to the subjective assessment of the patients anterior chamber angles appearing narrow. The use of OCT is not the standard of care in the absence of clinical evidence to suspect narrow-angle glaucoma. For the reasons provided, the anterior OCT (CPT 92132) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the service at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewer number one is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in ophthalmology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in ophthalmology 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 reimbursement for right and left occipital nerve block injections and prospective authorization and coverage for future right and left occipital nerve block injections for treatment of the enrollees bilateral occipital neuralgia.  Findings:  The physician reviewer found that The physician reviewer found there is sufficient support for the services at issue in this patients case. There are randomized, prospective, double-blind studies which show the effectiveness of occipital nerve blocks for the treatment of occipital neuralgia and to decrease the frequency of migraine headaches. Further, clinical practice guidelines support the performance of occipital nerve blocks for occipital neuralgia. The medical evidence supports occipital nerve blocks in this clinical setting. Therefore, right and left occipital nerve block injections and future right and left occipital nerve block injections were and are likely to be more effective than other treatment options. Final Result: Two of three reviewers determined that the services at issue were and 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: Physician reviewer number one is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Vemlidy 25 mg 1QD for 12 months for treatment of the enrollees chronic hepatitis B virus. Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. For this reason, the request for Vemlidy 25 mg 1QD for 12 months is medically necessary for the treatment of this patients chronic hepatitis B. 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 authorization and coverage for rituximab for treatment of the enrollees systemic sclerosis.Findings: The physician reviewers found that this is a case of systemic sclerosis manifested by skin findings, gastroesophageal reflux disease (GERD) with esophagitis, Raynauds and myopathy. Previous therapy has included methotrexate which was stopped for three weeks due to axillary lymph node, and mycophenolate. However, the patients records do not document treatment or a contraindication to treatment with cyclophosphamide. The current literature demonstrates a possible benefit of rituximab in skin symptoms, but larger, randomized controlled studies have not been performed to confirm the safety and effectiveness of this treatment. Given these findings, the requested rituximab is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication 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: Two physician reviewers are board certified in internal medicine with sub-specialty certifications in allergy and immunology and rheumatology and are actively practicing. One physician reviewer is board certified in neurology with sub-specialty certification in neuromuscular medicine and is actively practicing.  The reviewer 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:The patient has requested reimbursement for the DecisionDx-Melanoma Assay performed on 2/22/17 for evaluation of the enrollees malignant melanoma. Findings:  The physician reviewer found that The DecisionDx-Melanoma Assay tests the tissue genetics of the melanoma to help stratify whether a melanoma is high risk for metastasis. The DecisionDx-Melanoma Assay test has shown some accuracy in thin melanomas. However, there is a lack of scientific evidence permitting conclusions concerning the effect of this test on health outcomes. The test is not considered routine standard of care and is not recommended by the National Comprehensive Cancer Network (NCCN) guidelines. Overall, there is a lack of published data to support its routine use. Since this test has not been demonstrated to provide a benefit more than established tests, the DecisionDx-Melanoma Assay provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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: Physician reviewer number one is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in dermatology 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 custom orthotics for treatment of the enrollees foot pain.  Findings: The physician reviewer has found that as noted in the medical literature, custom orthotics are supported as medically necessary after a patient has failed treatment with strapping and over the counter type foot supports. Review of the documentation provided does not support demonstrate that the patient has failed treatment with strapping and over the counter type foot supports. Thus, the requested custom foot orthotics are not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in podiatry 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.