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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Botox treatment performed on 8/12/15 and 1/13/16. Findings:  Two physician reviewers found that chronic exertional compartment syndrome is defined as reversible ischemia that is unresponsive to the expansion of muscle volume that occurs with exercise. Chronic exertional compartment syndrome is distinct from functional popliteal artery entrapment which refers to intermittent arterial compression. Compartment syndrome in the leg is most common in the anterior and lateral compartments and least common in the posterior compartments where this patients injections were performed. There is a lack of studies comparing Botox to standard surgical treatment for either chronic exertional compartment syndrome or functional popliteal artery entrapment. In this case, the providers notes indicate that after the initial 8/12/15 injection the patients symptoms returned and he was retreated on 1/13/16, and the patients symptoms returned again. Final Result: Two reviewers determined that the services at issue were 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 orthopedic surgery and is actively practicing. One physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for treatment of the enrollees chronic 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. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa tablets 400/100 sofosbuvir/velpatasvir tablets 400/100 mg for 12 week duration or Harvoni 90/400 mg for 12 week duration for treatment of the enrollees hepatitis C virus.Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. The patient should be considered treatment-naive as she failed interferon/ribavirin rather than PEG-interferon/ribavirin. Per the guidelines, Epclusa is recommended as first-line for treatment-naive, genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). If the patient were considered treatment-experienced with PEG-interferon/ribavirin, the recommendation would be the same, based on ASTRAL-2 (Foster, et al).  Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, Epclusa is supported as medically necessary for the treatment of this patients hepatitis C infection. Per the guidelines, the request for Harvoni is not supported in this case, as the ledipasvir component does not have sufficient activity against genotype 2, and the sofosbuvir component alone is insufficient. Therefore, the request for Harvoni is not supported as medically necessary for the treatment of this patients hepatitis C infection. Specifically, Epclusa tablets 400/100 sofosbuvir/velpatasvir tablets 400/100 mg is medically necessary for 12 week duration but Harvoni 90/400 mg for 12 week duration is not medically necessary for the treatment of this patients hepatitis C infection Final Result: The reviewer determined that portion of the requested medications 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 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

An enrollee has requested reimbursement and prospective authorization and coverage for continued acute inpatient hospitalization and residential treatment center services upon discharge from this acute inpatient stay.   Findings:  The physician reviewer found that the patient was hospitalized for a month.  The patient was unable to sustain any therapeutic momentum from the admission.  The patient had previously failed outpatient services, intensive outpatient programming and partial hospitalization.  Regarding a specific episode of care, the patient was difficult to manage from the outset despite the highly-specialized setting of an acute inpatient psychiatric unit.  Upon presentation, the patient was agitated, paranoid and manic.  The records noted that the patient was hypomanic, paranoid, delusional, labile, agitated and suspicious.  This patient has a severe and chronic mental illness associated with poor clinical outcomes, significant comorbidity, erratic behaviors and elevated suicide rates.  Due to the patient's adherence to treatment, lack of insight and protracted illness burden with substance use, the patient poses a significant threat to himself and the community if inadequately treated from the psychiatric perspective.  Based on the medical record, the episode of illness that prompted the admission had not resolved by a specific date while a less restrictive treatment setting would have been inadequate and unsafe at the time.  The patient would have more than likely been promptly re-admitted if discharged.  Further, considering the unsupportive and strained parental dynamic at home coupled with a formidable symptom complex that has not responded to an array of prior treatment interventions, step-down to the residential level of care to further consolidate the treatment gains related to his addictions and acute-on-chronic mental illness would be safe, appropriate and consistent with good medical practice.  Final Result: The reviewers 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 physician 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 authorization and coverage for OxyContin, Roxicodone, Ativan, and clonazepam and palliative care for treatment of the enrollees human immunodeficiency virus (HIV), idiopathic peripheral autonomic neuropathy, and chronic pain syndrome. Findings:  The physician reviewer found that the patient is on an extremely high dose opioid and benzodiazepine regimen. Further, the patient has a documented failed urine screen from October 2016 with positive findings for multiple non-prescribed agents. Additionally, the patient does not have a medical condition that at this time qualifies him for palliative care. Given the above findings of extremely high dose opioids with two concurrent benzodiazepines medications and a failed urine screen, the above requested OxyContin, Roxicodone, Ativan, and clonazepam and palliative care are not medically necessary. Final Result: The reviewer determined that the requested medications and 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 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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for morphine sulfate ER 15 mg twice per day. Findings:  The physician reviewer found that the records indicate that this patient underwent a random urine toxicology. The results indicated multiple non-prescribed agents including amphetamines, cannabis, hydrocodone and codeine. The provider subsequently discontinued morphine secondary to the non-compliance. Further treatment with opioids is therefore not indicated given the substantial issue of non-compliance with treatment plan. Non-opioid treatments should be pursued.  Final Result: The reviewer determined that the 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: Upheld Decision of Health Plan

An has requested authorization and coverage for magnetic resonance imaging (MRI) of the pelvis. Findings:  the physician reviewer found that for diagnostic purposes, the National Comprehensive Cancer Network (NCCN), guidelines recommend pelvic MRI for patients with clinical T3-4 disease, or T1-2 disease with high risk greater than 10% of lymph node involvement. According to the submitted documentation, this patient does not meet the criteria outlined in the NCCN guidelines. The NCCN guidelines do not discuss MRI for radiation planning. Instead, MRI may be used to better select patients with intermediate risk cancer for single modality brachytherapy versus multimodality brachytherapy plus external beam radiation. This patient is diagnosed with low risk disease.  MRI, for planning purposes, is generally considered for more accurate delineation of the prostate, urethra and surrounding normal tissues as a result of the superior soft-tissue delineation of the prostate and adjacent normal tissue structures with MRI. With HDR brachytherapy, the urethra is well-visualized, often with the use of hyperechoic aerated gel placed within a Foley catheter that can be seen on ultrasound and the surrounding tissues are well defined with computed tomography imaging. Recent data describes the use of MRI for planning with low-dose rate (permanent seed implant) and pulsed dose rate prostate brachytherapy, suggesting that MRI improves treatment planning. However, large studies have not been performed. Moreover, the submitted documentation provides no specific rationale for why an MRI was ordered other than for planning. There were no clinical records specifically addressing the medical necessity of the requested services. As such, the medical studies do not support the use of MRI for planning and is not widely accepted as a standard.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Cialis 5 mg daily, #30 per 30 days for treatment of the enrollee, who has been diagnosed with benign prostatic hyperplasia and erectile dysfunction. Findings:  The physician reviewer found that Phosphodiesterase-5 (PDE-5) inhibitors like Cialis have been studied in men with benign prostatic hyperplasia/lower urinary tract symptoms.  The efficacy of Cialis for benign prostatic hyperplasia/lower urinary tract symptoms is based on findings that show the expression of the PDE-5 enzyme in the lower urinary tract (prostate, bladder, urethra and vascularity).  PDE-5 inhibition results in smooth muscle relaxation and may increase pelvic blood perfusion, which is suspected to affect smooth muscle tone.  Clinical studies have demonstrated that Cialis 5 mg once daily leads to statistically significant improvements in International Prostate Symptom Score (IPSS) as early as one to two weeks after beginning therapy.  The standard of care for treatment of patients with benign prostatic hyperplasia includes alpha blockers and 5 alpha reductase inhibitors.  Studies comparing alpha blockers and daily Cialis used a monotherapy have failed to prove superiority of daily Cialis over alpha blocker therapy.  Hence, the use of Cialis for treatment of benign prostatic hypertrophy is not medically necessary.  Cialis 5 mg once daily is an option for treatment of men with erectile dysfunction.  However, the current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy.  In addition, the current medical literature does not support improved efficacy of Cialis over equivalent dose of sildenafil (Viagra).  Hence, the use of Cialis for treatment of erectile dysfunction is not medically necessary.  All told, Cialis 5 mg daily, #30 per 30 days is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in urology 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 advanced lipoprotein testing for evaluation of the enrollees hypercholesterolemia. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Based on the records provided, this patient presented with some coronary risk.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.   These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), myeloperoxidase, sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Thus, advanced lipoprotein testing performed was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hydrocodone/APAP 10/325 mg, #60 per 30 days for treatment of the enrollees pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has migraine headaches and abdominal pain for which she has been taking hydrocodone/APAP.  This is not recommended therapy for migraine headaches and is of questionable value for nonspecific abdominal pain.  The patient noted she had back pain after an automobile accident, but there is no documentation of a physical examination confirming lumbar radiculopathy or back injury, nor is there imaging to confirm back pathology.  Clinical practice guidelines do not support prescribing opiates in this clinical setting.  All told, hydrocodone/APAP 10/325 mg, #60 per 30 days is not medically indicated for the 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 physician 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 reimbursement for a joint jaw oral device (occlusal orthotic device).Findings:  The physician reviewer found that there is sufficient support for the device at issue in this clinical setting.  Splint therapy has been shown to be beneficial in patients with temporomandibular joint disorder and myofascial pain.  Oral devices have been shown to decrease symptoms in 70 to 90% of cases.  The majority of patients with temporomandibular joint disorder can be treated with a single stabilization splint. Final Result: The reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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: enrollee has requested reimbursement for computed tomography (CT). Findings:  The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  Temporomandibular joint dysfunction is an umbrella term used to describe pain and dysfunction of the muscles and skeletal structures involved in mastication.  It is a symptom complex, as opposed to a specific disease or illness, and as much as 20-30% of the entire adult population is affected at some point in their lives.  Etiologies range from a simple dental abnormality, such as an uneven dental filling, to significant malformations of the temporomandibular joint.  As such, there is considerable variation in the diagnostic evaluation.  In very general terms, possible etiologies include trauma, meniscal disc displacements, degenerative arthritis, bruxism, occlusal problems, and even psychological issues.  Per the records, the patient had a specialized CT scan generally performed in dental or oral surgery offices known as a coned beam computerized tomogram (CBCT) that has been designed specifically to evaluate the facial bones, teeth, and temporomandibular joints.  Cross-sectional imaging, including CT and magnetic resonance imaging (MRI), has been developed to evaluate the temporomandibular joint.  The major disadvantage of MRI is the poor evaluation of bone.  There is sufficient data available to support the use of CT to evaluate the temporomandibular joint as opposed to other modalities.  Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in diagnostic radiology 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.