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 Mavyret 100-40 mg tablets for eight weeks. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. All told, the requested medication regimen 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 reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is sufficient support in the documentation provided for the medical necessity of the services at issue in this clinical setting. During the disputed dates, the patient remained symptomatic. The patient was noted to have angry, anxious, and irritable mood, poor sleep, pressured speech and expressed suicidal ideation. He was aggressive at times and not fully participating in the recommended treatment plan. The patient was documented as having lack of support outside of the treatment facility, high cravings, and high risk of relapse.   At some point in the treatment timeline, the patient stepped down from residential level of care to a sober living facility.  The patient was documented as relapsing and returned to residential treatment. The patient expressed desire to maintain sobriety. The American Society of Addiction Medication (ASAM) criteria have a set of objective guidelines used by clinicians to assist with treatment planning, advocates for service intensity provided in the least intensive but safe treatment setting. ASAM criteria also advise that length of service should be determined by the patients progress with the treatment plan as determined by the patient and treatment providers. In this case, the patient is documented as having high relapse potential, unstable recovery environment, lack of coping skills, lack of understanding of the severity of his use, inability to recognize triggers and poor impulse control as evidenced by his relapse after step-down from residential care. Based on current medical literature, ASAM criteria and the patients documented clinical history, the patients stay at the residential level of care was and is medically necessary for treatment of the patients medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for a rheumatologist referral. The Health Plan has denied this request indicating that the requested services are not medically necessary for evaluation of the enrollee who has a history of psoriatic arthritis.Finding: There is sufficient support in the medical literature for the requested services in this clinical setting. This is a patient with a history of psoriasis and PsA.  The record indicates that she is currently having active skin symptoms and joint pains. The patients medical condition is a lifelong chronic condition needing immunosuppressive agents. As such, a referral to rheumatology to evaluate and manage this patients symptoms is medically indicated. Therefore, a rheumatologist referral has been established as medically necessary for the evaluation of this patients medical condition.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 internal medicine with sub-specialty certification in rheumatology 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 enrollee has requested has requested authorization and coverage for hip replacement surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollees bilateral hip pain.Finding: In this patients case, evidence based medical guidelines and peer reviewed criteria have been met for the requested services. Evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been considered or implemented. Obesity is a relatively common finding in candidates for total joint arthroplasties. There is limited evidence to support the recommendation of weight loss in the year prior to total hip or knee replacement and to determine the effectiveness of short term nonpharmacological, nonsurgical weight management interventions on patient and surgical outcomes. A study involved more than 104,000 patients who underwent elective total joint arthroplasty for hip and knee osteoarthritis, 40 and 60 %, respectively, were obese. While there was some indication that obesity is associated with increased risks for receiving a total joint arthroplasty, providers doing large number of cases had a very small complication rate. Six months after total joint replacement, severely or morbidly obese patients reported excellent pain relief and substantial functional gain that was similar to the findings in other patients. The authors concluded that while obesity is associated with a greater risk of early complications, obesity in itself should not be a deterrent to undergoing total hip arthroplasties to relieve symptoms. A review by that pertained to bariatric surgery prior to total hip or knee arthroplasty. The authors concluded that bariatric surgery does not significantly reduce the complication rate or improve the clinical outcome. As such, the medical literature indicates that bariatric surgery prior to a total hip arthroplasty does not reduce the complication rate.  Based upon the above literature review, there does not appear to be a contraindication to undergoing a total hip arthroplasty in this patients case. As such, the requested hip replacement surgery is medically necessary for treatment of this patients medical condition.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 56-year-old female enrollee has requested authorization and coverage for sclerotherapy (six treatments). Findings: The physician reviewer found that the request for sclerotherapy (six treatments) is not medically necessary for treatment of the patients medical condition. The treatment for varicose veins is to identify the patient, and offer conservative therapy. If the patient is successful with conservative therapy, no further intervention is required. However, if the patient fails conservative therapy, then ablation and removal of the axial veins and interruption of significant non axial accessory varicosities is indicated. Traditionally high ligation of greater saphenous vein (GSV) with stripping and stab avulsions are recommended with probable maximum symptomatic relief of up to 10 years. Currently, endovenous ablation of greater saphenous vein in combination with stab avulsions is the standard of care. There is ample medical literature suggesting that both laser and radiofrequency ablation of the GSV is superior to high ligation and GSV stripping. It produces the same clinical efficacy, has a shorter recovery time, greater patient acceptance. Significantly higher failure and complication rates were seen in short saphenous vein and anterior saphenous vein treatment as compared with GSV treatment. The medical literature suggests that the current place of sclerotherapy in modern clinical practice is limited to the treatment of accessory recurrent varicose veins following surgery and thread veins. All told, the requested service is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested service 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 surgery and vascular 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: The enrollee has requested has authorization and coverage for acupuncture services. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of back and shoulder pain.Finding: The request for acupuncture services is medically necessary and appropriate at this time.  The patient reported having shoulder pain, shoulder stiffness, back pain, and associated arm pain. There were symptoms of numbness and paresthesia.  Research supports the use of acupuncture for shoulder pain. Medical literature shows single point acupuncture in association with physiotherapy improves shoulder function and alleviates pain. Additionally, the improvement is accompanied by a reduction in the consumption of analgesics. Additionally, a study found that contralateral acupuncture in the treatment of chronic shoulder pain demonstrated beneficial effects in terms of pain and function.  According to medical literature, acupuncture is effective for the treatment of chronic musculoskeletal, headaches, and osteoarthritis pain. The documentation provided demonstrates that this patient has a musculoskeletal condition for which acupuncture is supported through research. Therefore, the requested services for acupuncture is medically necessary for the treatment of the patients medical condition.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 oriental 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: Upheld Decision of Health Plan

A 29-year-old male enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that The medical services provided were not emergent in nature for treatment of a psychiatric emergency medical condition. Emergency medical services, from the psychiatric perspective, are traditionally conceptualized hospital-based, specialty care for individuals demonstrating grave disability and/or imminent threat to self or others due to a mental illness. In this case, the patient struggled in all functional domains due to his disordered thinking. He had a court-appointed conservator and a history of nonadherence, overdosing and multiple hospitalizations. However, considering the case in its entirety, relevant literature, and current treatment standards, the services in dispute were not emergent for treatment of a psychiatric emergency medical condition.Final Result: The reviewer determined that the enrollee did not receive psychiatric emergency medical services on the dates of service at issue. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for autonomic testing (tilt table testing). Findings:  Three physician reviewers found the submitted documentation supports the requested services in this clinical setting. An emotional component, although considered, has been ruled out as the major etiology of the patients dizziness and lightheadedness. A unifying diagnosis is needed, whether its etiology resides in the autonomic, central nervous, or immune-mediated systems. An appropriate next step is to assess the autonomic nervous system with a tilt table test to rule out a primary autonomic system dysfunction. Per the medical evidence, autonomic dysfunction generally starts around the age of 15.  Tilt table test is the initial evaluation in the evaluation of possible autonomic dysfunction. All told, the requested autonomic testing (tilt table testing) is likely to be of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 are board certified in neurology with special qualification in child neurology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for electromagnetic navigational bronchoscopy (ENB)for treatment of the enrollee with history of pulmonary nodules. Findings:  The physician reviewer found that transthoracic needle biopsy (TTNB) has a better diagnostic rate, there is a higher risk for pneumothorax, greater than 10% when compared to 3% to ENB.  The primary disadvantage of TTNB is that a pneumothorax develops in 11% to 24% of patients and 5% to 14% require insertion of a chest tube. The National Comprehensive Cancer Network (NCCN) clinical practice guidelines for non small-cell lung cancer state that the strategy for diagnosing lung cancer should be individualized and the least invasive biopsy with the highest diagnostic yield is preferred as the initial diagnostic study. In 2013, the American College of Chest Physicians issued updated guidelines on the diagnosis of lung cancer. Regarding ENB, the guideline states, In patients with peripheral lung lesions difficult to reach with conventional bronchoscopy, electromagnetic navigation guidance is recommended if the equipment and the expertise are available. This patient meets the recommended criteria for ENB. For patients with peripheral (outer one-third) nodules, either navigation bronchoscopy, radial endobronchial ultrasound (EBUS) or TTNA transthoracic needle aspiration (TTNA) are preferred. All told, the requested ENB is likely to be more effective than the standard options available for evaluating this patients medical condition.Final Result: Two of the three reviewers determined that requested services are 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 internal medicine with sub-specialty certification in pulmonary disease 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 authorization and coverage for Mavyret 100-40 mg. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 infection regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg 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 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 lumbar kyphoplasty. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. The records show a mild L1 endplate compression fracture of unknown age. Kyphoplasty has not been shown as a superior treatment option for lumbar compression fractures. Recent literature shows it is not more effective than sham treatment. As such, lumbar kyphoplasty is not likely to be more beneficial than other available options for treatment of this patients medical condition. Final Result: Two of the three reviewers determined that 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 orthopedic 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 authorization and coverage for immunotherapy (once per week for 52 weeks (two sets)). The submitted documentation supports the medical necessity of a portion of the requested services. Allergen immunotherapy is defined as the repeated administration of allergen extracts to patients with allergic diseases for the long-term relief of symptoms. It has been demonstrated to be effective in immunoglobulin E (IgE) mediated diseases, particularly in patients with a limited number of allergies. Subcutaneous immunotherapy has been shown to be effective in patients with allergic rhinitis, as demonstrated by significantly decreased usage of allergy medications. Immunotherapy also has demonstrated efficacy in seasonal asthma. Most immunotherapy protocols are divided into an updosing phase, generally involving weekly injections for up to 16 weeks, followed by several (up to five) years of monthly injections. A more contemporary means of providing immunotherapy is via the sublingual route. For this patient with severe allergic rhinitis, moderate persistent asthma and environmental allergies, immunotherapy may provide some benefit. However, the current medical evidence does not support the medical necessity of the requested regimen of weekly injections for 52 weeks. Based on the literature, weekly injections for 16 weeks followed by monthly injections for maintenance is medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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 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.