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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for 90-count of 40 mg of OxyContin each month and 90-count of 10 mg of OxyContin each month for treatment of the enrollees chronic neck pain. Findings:  The physician reviewer found that several requirements for opioid prescribing have not been documented, so the need to use them as the primary medication treatment strategy for pain has not been established in this clinical setting. The Centers for Disease Control and Prevention (CDC) state that when opioids are started, providers should prescribe the lowest effective dosage. The CDC states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate release opioids instead of extended release/long-acting (ER/LA) opioids. Providers should use caution when prescribing opioids at any dosage and should carefully reassess evidence of the individual benefits and risks when considering increasing dosage to 50 or greater morphine milligram equivalents (MME) per day, and should avoid increasing dosage to 90 or greater MME per day. It is recommended to carefully justify a decision to titrate dosage to 90 or greater MME per day. In the documentation available for review, no objective treatment goals for pain and function are noted for this patient to continue on the requested medication. There is no medical evidence based rationale is given for this high of a MME/day by the provider or by the patient. It is unclear what the plan is for any unseen future pain insults the patient would experience while on the requested medication quantity. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. There is no documentation that other non-pharmacological alternatives of addressing this patients pain have been initiated. The record does not mention completion of behavior therapy despite much research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. Final Result: The reviewers determined that the medication quantity was not and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the medication ocrelizumab (Ocrevus) for treatment of her relapsing remitting multiple sclerosis (MS). Findings:  All three physician reviewers found that the medical literature supports the use of Ocrevus in relapsing remitting multiple sclerosis. Additionally, this medication is approved by the U.S. Food and Drug Administration. The record indicates that this patients clinical status is most consistent with relapsing remitting multiple sclerosis.  In the early years of her diagnosis, while on various injectable therapies, she has experienced numerous relapses with accumulated disability and periods of remission.  Disease and disability progression was halted upon transition to natalizumab. Her contrast enhanced magnetic resonance imaging corroborates her clinical picture, as this has been stable. Contraindications include active hepatitis B infection and history of life threatening infusion reactions to ocrelizumab, neither of which the patient has. Based on the documentation provided and the medical literature, ocrelizumab (Ocrevus) is likely to be more effective than the available standard therapies for treatment of this patients medical condition. Final Result: Three reviewers determined that the requested medication is 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: Three reviewers are board certified in neurology and are actively practicing. The reviewer are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks 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, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy 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. Delay in treatment may result in decreased survival. For these reasons, Epclusa once daily for 12 weeks is medically necessary for the treatment of the 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity for the services at issue in this clinical setting. By the discharge date, he had no post acute withdrawal symptoms. There was no evidence of suicidal or homicidal ideation. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The progress notes stated that he was engaged and participating well.  He was motivated.  His mood was sad and anxious, and his affect was flat.  On the date of service in question, he was cooperative, and his affect was reactive and mood congruent.  The patients thoughts were linear and goal directed. He had identified a sponsor. He was using mindfulness and relaxation techniques.  On the date of service in question, he reported ongoing memory problems, but denied cravings. He was motivated and appeared to be working the program. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care. The progress notes documented that he was cooperative and participating in his treatment plan.  There were no new problems. There was no evidence that returning him to his environment would result in decompensation or relapse. He had extensive prior experience with AA meetings, and had obtained a sponsor. Based on the submitted records, this patient no longer required the structure of residential level of care by the date of service in question.  He could have stepped down to an ambulatory level of care, such as intensive outpatient program. All told, the RTC services received during the dates of service in question were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services were not medically necessary for treatment of the patients medical condition. During the dates in dispute, the patient had no post-acute withdrawals. She was not suicidal or homicidal, and she was medically and psychiatrically stable. She appeared to be engaged in her recovery. She was cognitively intact. She was not manic or psychotic. Per the discharge summary, she has had no previous treatment for substance dependence problems and there was no evidence to suggest that she would not succeed at a lower level of care. Her recovery could have continued at a lower level of care, in conjunction with additional community based Alcoholics Anonymous meetings. Thus, residential treatment center services were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in addiction 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 authorization and coverage for oral appliance therapy treatment and temporomandibular joint (TMJ) treatment for treatment of the enrollees sleep apnea and TMJ disorder. Findings: The physician reviewer found that TMJ and orofacial pain disorders can have a wide variety of causes. Stabilization splints are one of multiple types of removable appliances that are commonly used to treat TMJ disorder. In general, stabilization splints are used in conjunction with other therapies like behavior modification, non-steroidal anti-inflammatory drugs (NSAIDs) or other pharmacotherapy, and physical therapy. When used as a short-term adjunct to other therapies, oral appliances can be reasonably expected to improve the patients symptoms. Mandibular advancement devices are a type of removable appliance used to reposition the mandible in a more forward position during sleep, allowing more room for the passage of air. These devices are effective for the majority of patients, especially for patients unable to tolerate CPAP. In this case, the patient was unable to tolerate CPAP. A mandibular advancement device is medically necessary to improve his OSA symptoms. Based, on the clinical documentation submitted for review and support in the peer-reviewed literature, the request for oral appliance therapy treatment and TMJ treatment is medically necessary for 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 dentistry 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 reimbursement for the residential treatment center (RTC) services provided for treatment of the enrollees substance abuse and eating disorder. Findings: The physician reviewer found that based upon the submitted documentation, the patient did not meet medical necessity criteria for RTC during the period at issue. Applying the level of care utilization system (LOCUS) criteria, the patient would have met the criteria for an intensive outpatient program (IOP) services from 10/1/16 through 10/18/16. The records indicate that the patient was at moderate risk of harm with no history of suicide attempts or suicidal ideation, but the patient reported that she had episodes of binge drinking to the point of intoxication (score of 3), moderate impairment in functional status due to ongoing problems with interpersonal relationships and social activities (score of 3), and significant psychiatric co-morbidity with bipolar disorder, anorexia nervosa, and alcohol use disorder (score of 3). The patients recovery environment is described as mildly stressful (score of 2) however, her family is documented to be supportive (score of 2). The patients treatment history includes moderate response to treatment with some sobriety typically under very structured settings (score of 3), and given the patients positive engagement and recovery (score of 2), the patient has a total score of 18, which is consistent with IOP services. Based on this criteria, the dates of service were not medically necessary. The patient could have been treated in a less restrictive environment in an IOP. The patient did not have any suicidal or homicidal ideation. The patient was motivated for treatment and she was sleeping well. The patient continued to require treatment, but this could have been done in a less restrictive environment in an IOP. Thus, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cochlear implants. Findings:  Three physician reviewers found that cochlear implantation is a recognized technology to improve patients perception of sound after development of hearing loss or, in the pediatric population, of establishment of hearing perception in children who were born with congenital hearing loss. However, the use of this technology is beneficial in patients with bilateral hearing loss to allow the patient a perception of hearing. While its use in patients with single sided deafness is growing, there are few randomized controlled studies in the literature to establish substantial outcomes of their utilization.  The patient did sustain a clinical impairment of her hearing with severe deafness on the left ear documented with several hearing tests and VNG as well as a normal MRI scan.  Those tests also demonstrated relatively normal hearing in the contralateral right ear, which remained non-affected by the initial sudden event. The patient has relatively normal hearing on the contralateral ear. Currently, although some of the medical literature supports cochlear implantation for patients who have single sided deafness, there is an absence of peer reviewed medical literature supporting data.  For these reasons, the requested cochlear implant is not likely to have a greater benefit over standard modalities for treatment of this patient. Final Result: 2 of 3 reviewers determined that the 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 physician reviewers are board certified in otolaryngology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing, procedure codes 81240, 81291, 82172, and 83698. Findings:  Three physician reviewers found that, in this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established. 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), sub-classifications of low density lipoprotein (LDL), high density lipoprotein (HDL) subclasses, lipoprotein (a), insulin, fibrinogen, genetic testing and homocysteine. Treatment change 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. Even though 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. Moreover, the services at issue are not standard for screening for cardiovascular or thromboembolic risk in this clinical situation. Therefore, the advanced lipoprotein testing, procedure codes 81240, 81291, 82172, and 83698 performed was not likely to have been more effective than any other available standard modality for the evaluation of this patients medical condition. Final Result: 3 of 3 reviewers determined that the services at issue were not likely to have been 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for tertiary level of care for evaluation of the enrollees breast cancer. Findings:  The physician reviewer has found that patients with ER positive disease often respond to endocrine therapy which has been associated with an improvement in progression and overall survival. The use of chemotherapy is reserved for patients who have extensive visceral metastases with evidence of end-organ dysfunction. In this case, a specialized consultation is warranted. As such, it is medically necessary for the patient to have a consultation with a breast specific oncologist to evaluate options for therapy and the strategize drug types based on her burden of disease and her intolerance of hormonal therapy. For the reasons provided, the request for tertiary level of care is medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested service is medically necessary for evaluation 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 medical 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 surgical aortic aneurysm repair for treatment of her ascending thoracic aortic aneurysm.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. If surgery is done, it would require replacement of the ascending aorta, which is a procedure with definite risks, including bleeding, infection, stroke, myocardial infarction and multi-organ failure. Surgery for ascending aortic aneurysms are not undertaken unless the aneurysm measures over 5.0 cm, or there are other compelling reasons, such as rapid expansion, concomitant aortic dissection or Marfans features. None of these are present in this patients case. The mainstay of treatment in patients with 4.0 cm ascending aortic aneurysms is surveillance. All told, the requested surgical aortic aneurysm repair is not medically necessary 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 thoracic and cardiac 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.