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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested applied behavior analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: Two reviewers found that ABA is effective in helping with maladaptive behaviors in school age children with autism. In addition, Hassiotis and colleagues concluded that ABA significantly increased community participation and decreased carer burden for children with autism and challenging behaviors. An abrupt discontinuation of ABA services is not indicated because it often causes regression. Thus, the continuation of ABA services are medically necessary. However, the requested frequency of ABA services are not indicated for this patient. In this case, a portion of the requested hours per month of ABA therapy, the requested hours per month of supervision and the requested hours per month of parent training provided forward was and is medically necessary for treatment of the patients autism.Final Result: Two reviewers determined that the portion of the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in pediatrics and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a 12-year-old enrollee has requested Mekinist for treatment of the enrollees ependymoma.  Findings: The physician reviewer found that patients with refractory or relapsed cancer that have exhausted standard treatments are usually considered for clinical trials. This may be particularly relevant for very rare cancers where even phase II studies may be not be effectively conducted due to poor accrual. Recently, it has become important to identify mutations that may be amenable to targeted therapy. A study of 86 patients was conducted by Von Hoff and colleagues. The authors reported progression-free survival on a regimen selected by molecular profiling was compared to progression free survival rate on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage. This patients tumor had mutational profiling done which revealed a BRAF mutation, V600E that has been described in melanoma, colon cancer, lung cancer, hairy cell leukemias, among others. Mekinist is an inhibitor of MEK kinases approved for use in metastatic melanoma with BRAF mutation (Wright and McCormack). The MEK kinases are within the same pathway as RAS and BRAF (Pylayeva-Gupta, et al). Thus, it is mechanistically appealing to apply Mekinist to tumors with constitutive RAS signaling such as this patients tumor. A phase I trial showed that Mekinist was tolerated at 2 mg twice daily with responses in patients with diverse cancers (Infante, et al). Given this support, the requested Mekinist is medically necessary for treatment of this patients ependymoma.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 oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested plasma rich platelet (PRP) injection for treatment of the enrollees right elbow pain.  Findings: Three physician reviewers found that the current medical literature pertaining to PRP use in sports medicine for nonsurgical therapy of tendinosis does not indicate the requested PRP injection is likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. The consensus is that more clinical studies are needed to evaluate the use of PRP as an orthobiologic treatment. There is currently insufficient evidence to support the use of PRP in the treatment of musculoskeletal soft tissue injuries such as ligament, muscle, and tendon tears and tendinopathies. Moraes and colleagues review included 19 small single center trials, 17 randomized and two quasi-randomized trials, and with 1,088 participants. The authors compared PRP with placebo, autologous old blood, dry needling, or no PRP therapy. These trials covered eight clinical conditions which included shoulder, elbow, and knee conditions. Tendinopathies were injected with PRP in five trials. The authors concluded that there is currently a paucity of evidence to support the use of PRP for treating musculoskeletal soft tissue injuries. Thus, the requested PRP injection is not likely to provide this patient with a superior health outcome when compared to standard available therapies.Final Result: Three reviewers determined that the requested service 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 physician reviewers are certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees medical condition. 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 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. All told, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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: Three physician reviewers are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Humira for the treatment of the enrollees medical condition. Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. Anti-tumor necrosis factor (TNF) agents are very effective in severe psoriasis affecting more than 10% of the skin surface. There are multiple studies in the peer-reviewed literature demonstrating the effectiveness and superiority of Humira compared to methotrexate. Gordon and colleagues assessed the efficacy and safety of Humira in patients with moderate to severe plaque psoriasis. The authors concluded that Humira significantly improved psoriasis and was well tolerated for 60 weeks with an improvement of over 75% in the skin psoriasis. Menter and colleagues performed a randomized, controlled phase III trial which showed that Humira is efficacious and well-tolerated in the treatment of chronic plaque psoriasis with a greater than 75% improvement in Psoriasis Area and Severity Index (PASI) scores. In addition, Saurat and colleagues compared methotrexate to Humira and found that Humira demonstrated significantly superior efficacy and more rapid improvements in psoriasis compared with either methotrexate or placebo after 16 weeks. In this case, the patient has psoriasis covering more than 90% of her body. There is evidence of possible psoriatic arthritis. She is intolerant of methotrexate with severe nausea. Given the severity of her disease, failure of methotrexate and evolving psoriatic arthritis, the request for Humira 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Sovaldi 400 mg, one tablet per week 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 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.  This applies regardless of fibrosis stage or viral load.  However, the guidelines no longer support the use of Sovaldi with ribavirin for treatment-naive genotype 2 patients.  Per the guidelines, the alternative medication regimens which are recommended are Epclusa, and Sovaldi with Daklinza.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the bilateral breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has extremely dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. Final Result: Two of three reviewers determined that the services at issue were 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 number one, two, and three are board certified in diagnostic radiology and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus genotype 1a. 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. Although prior use of ribavirin is unclear in this case, the guidelines recommend that non-cirrhotic patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the 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: An enrollee has requested authorization and coverage for intrathecal baclofen pump trial for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the patient has a history of cervical myelopathy. The patient underwent resection of a hemangioblastoma as described above. The patient does not have physical examination findings of spasticity. The patient has normal reflexes without upper motor neuron signs and with no reported increase in muscle tone using established scales such as the Ashworth or modified Ashworth Scale. However, the patient has complaints of spasms which affect the upper extremities. Spasms are not the same as spasticity and, in this case, the patient's spasms may represent the residual sequela of his cervical myelopathy. The patient has undergone extensive conservative treatments and remains symptomatic more than 2.5 years after surgery. Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is board certified in physical medicine and rehabilitation 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 parent of an enrollee has requested authorization and coverage for an applied behavioral analysis (ABA) aide in school services. Findings:  Three physician reviewers found that the requested services are medically necessary for treatment of the patients medical condition. An ABA aide in the classroom can be highly successful. In this case, an ABA aide in the classroom is medically necessary to assist with the patients transition to the next grade level. Moreover, the occupational therapy report indicates that the patients interpersonal skills are limited. An ABA aide to assist the patient in the school to help with his social skills is medically necessary. Final Result: The reviewers 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: Two reviewers are board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is 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 Norco for treatment of her medical condition.   Findings:  The physician reviewer found that in the Argoff review article, noting specifically chronic non-cancer pain, short and long acting opioid have been found to be effective. The review also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. However, in this case, using the opioid risk tool (ORT) evaluation with the current notes provided, this patient is at high risk. The patient has documented chronic headaches, back pain, and dysmenorrhea but she also presents with a history of behavioral health issues, drug abuse, and post-traumatic stress disorder from prior events in her life. The patient only recently completed chemical dependency recovery and while opioids may be considered a part of standard of care when treating chronic pain conditions, opioids are considered to be highly addictive. Therefore, in light of the submitted documentation and the patients medical history, the requested medication is not medically necessary for treatment of this patient.   Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 suction lipectomy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that in this patients case, there is well-documented evidence of lipedema of the lower extremities.  This has affected her function with chronic pain and difficulty with ambulation.  Conservative management has included attempted weight loss, exercise, compression stockings, physical therapy, manual self-compression and lymphatic drainage without resolution.  Photographs provided show a significant condition of the lower extremities with sparing of the feet consistent with her diagnosis of lipedema.  Liposuction is a well-known therapy for lipodystrophy and has been shown to provide possible functional improvement in lipedema.  The current medical evidence supports the requested services in this clinical setting.  This patients lipedema is significantly affecting her function, and she has failed treatment with reasonable conservative measures.  Therefore, the requested suction lipectomy is medically necessary for the treatment of this patient. Additionally, the requested services are also reconstructive in nature.  This patients condition constitutes an abnormal structure of the body.  She has abnormal enlargement of the extremities that are out of proportion to uninvolved structures.  This is a developmental abnormality, as this appears to have begun after puberty.  The planned surgery will be performed to improve function.  Additionally, the requested suction lipectomy is likely to provide more than a minimal improvement in the appearance of the lower extremities.  In sum, the requested suction lipectomy is reconstructive in nature and is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are reconstructive in nature 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 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.