Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensity modulated radiation therapy for treatment of his medical condition. Three physician reviewers found that because surgery for cervical esophageal cancer would require a pharyngo-laryngo-esophagectomy, chemoradiation is the treatment of choice.  The intensity modulated radiation therapy technique allows the optimization of target volume coverage while allowing reduction of the dose to surrounding organs at risk.  Therefore, an increased total dose could be achieved with better coverage of the target volume.  In a study comparing three-dimensional conformal radiation versus intensity modulated radiation therapy, Freilich and colleagues noted that intensity modulated radiation therapy-based chemoradiation for esophageal cancer resulted in significantly less toxicity.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested intensity modulated radiation therapy is likely to be of greater benefit than other treatment options.  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 radiation oncology 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 intravenous immunoglobulin therapy delivered in an inpatient hospital care setting for treatment of her common variable immune deficiency. The physician reviewer found that the medical records do not document that the patient had a significant reaction to the immunoglobulin therapy.  There is a lack of evidence of serious side effects during or following the treatment which would necessitate services in an inpatient hospital care setting.  The medical literature notes that serious side effects after intravenous immunoglobulin are very rare if infusions are given over an extended period in a well hydrated patient.  In this case, it may be appropriate to deliver her next infusion in an infusion center.  She could be pre-medicated and then receive the infusion over seven hours with careful observation of any side effects.  This could also be done in the providers office.  Assuming no documentation of side effects, subsequent infusions could be administered in her home.  All told, the requested intravenous immunoglobulin therapy delivered in an inpatient hospital care setting 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 internal medicine with sub-specialty certification in infectious 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 intensive outpatient treatment for treatment of her anorexia nervosa and obsessive compulsive disorder. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was engaged in active treatment that included psychiatric and nutritional services, family interventions, and both individual and group therapies.  Additional factors consistent with parameters established by the American Psychiatric Association that warranted ongoing intensive outpatient program care included the need for structure to help with weight management and dietary habits, and her significant psychiatric comorbidity of excoriation disorder and obsessive compulsive disorder.  Further, the step-down transitioning from partial hospital to intensive outpatient program, prior to outpatient services, is a well-accepted clinical progression in community practice.  Per the medical records, the patient remained at elevated risk for undue morbidity and admission to a higher level of care in the absence of intensive outpatient program treatment.  All told, the services at issue were medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Harvoni for treatment of her hepatitis C.   Findings:  Two physician reviewers found that per the current medical evidence, an accurate assessment of fibrosis is vital in assessing the urgency for treatment.  Based upon American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, treatment is recommended for all patients with chronic hepatitis C infection, except patients with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Immediate treatment is assigned the highest priority for those patients with compensated cirrhosis, advanced fibrosis, liver transplant recipients, and patients with severe extrahepatic hepatitis C.  In this patients case, a recent fibrosis stage is needed in order to establish the medical necessity of the requested medication.  All told, the requested 12 weeks of Harvoni is not medically indicated for the treatment of this patient.  Final Result:  Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 a motorized wheelchair for treatment of his low back pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested motorized wheelchair. According to the documentation submitted for review, the patient does not have impairments that would preclude the use of a walker for accomplishing his basic mobility-related activities of daily living. The physical examination noted that the patient was ambulating with a walker. He has some weakness at the left lower limb that could be addressed with an orthosis. The orthosis that he has can be adjusted for better fit if there is pain at the lateral foot. In addition, more prolonged mobility-related needs could be addressed with a manual wheelchair. He does not have documented impairments that would preclude the use of an appropriately fitted manual wheelchair. Poor tolerance and endurance with manual wheelchair mobility can be addressed with strengthening and conditioning, not by avoiding physical activity. Finally, the patient does not live in a residence that is accessible to a power mobility device. Based on the clinical documentation submitted, a motorized wheelchair is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 tramadol for treatment of her chronic pain syndrome.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  Tramadol is considered a mild synthetic opioid.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that chronic opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  Chronic opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The current medical evidence does not support the requested medication quantity in this clinical setting.  All told, the requested tramadol is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication quantity 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 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:  An enrollee has requested facial feminization surgery for treatment of her gender dysphoria.  The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care regarding the medical necessity of sexual reassignment surgery (SRS) including facial feminization surgery, `Professionals who provide services to patients with gender conditions understand the necessity of SRS, and concur that it is reconstructive, and as such should be reimbursed, as would any other medically necessary treatment.` The submitted documentation demonstrates that multiple providers have documented the patients longstanding history of gender dysphoria. Of particular concern to the patient is the presence of masculine facial features. The photographs provided confirm the presence of masculine facial features. A study by Ainsworth and Spiegel found that facial feminization surgery resulted in improved mental health related quality of life in male-to-female transgender individuals. As such, the proposed procedures of brow lift, frontal bossing, orbital reshaping of brow, hardware plates and screws for frontal set back procedure, rhinoplasty, septoplasty, lip augmentation and chin/jaw contouring are medically necessary for treatment of this patients gender dysphoria. These procedures also meet reconstructive surgery criteria, as the presence of the patients masculine facial features represents an abnormal structure of the body due to the patients gender dysphoria and these procedures would be expected to create a normal appearance as well as provide more than minimal improvement in the patients appearance. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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 Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. Moreover, recommendations for treatment-experienced chronic HCV patients with genotype 1b support Harvoni stating Recommended for treatment-experienced patients with HCV genotype 1b infection: Daily fixed-dose combination of ledipasvir/sofosbuvir for 12 weeks is recommended for treatment-experienced patients with HCV genotype 1b infection. All told, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xeljanz for treatment of her medical condition.  Two physician reviewers found that the superior efficacy of the requested medication has not been established in this patients case.  There is a lack of clinical studies demonstrating the superior effectiveness of Xeljanz in this clinical setting.  The medical literature does not support the requested medication for the treatment of this patient.  A thorough work-up to confirm that this patient has rheumatoid arthritis is appropriate.  Therefore, the requested medication Xeljanz is not likely to be of greater benefit than other treatment alternatives. Final Result: Two 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: All three reviewers are board certified in dermatology 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 the central auditory processing disorder (CAPD) test for evaluation of his behavioral health condition. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. In general, central auditory processing refers to several systems involved in both verbal and nonverbal communication. Since there are multiple proposed mechanisms, the term central auditory processing disorder (CAPD) is rather non-specific with regard to etiology. There is a lack of adequately-powered, well-designed studies demonstrating the usefulness of testing. Carpenter and colleagues recommended additional research investigating the clinical utility of [central auditory processing] testing for individuals with autism spectrum disorder. However, testing is not part of routine assessment for autism spectrum disorder. In this case, the patient is receiving comprehensive, clinically appropriate care for his medical conditions. These services include speech therapy which represents a reasonable intervention aimed at compensating his language and communication deficits. Since the clinical value of CAPD testing for adults is not established in the peer-reviewed medical literature, and in the absence of recommendation for testing by his treatment team, the requested services are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Harvoni for medical treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The guidelines indicate that urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help patients avoid untoward complications from advanced disease, such as liver failure and extrahepatic manifestations of hepatitis C.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result:   Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Sovaldi and ribasphere for 12 weeks for treatment of her hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help patients avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.   All told, the requested Sovaldi and ribasphere for 12 weeks are medically indicated for the treatment of this patient. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.