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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Butrans patches for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  The physician reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  The current medical evidence does not support the requested medication in this clinical setting.  Therefore, the requested Butrans patches are 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 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 shoe inserts for treatment of her medical condition.  Findings: The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. In this case, the patient presents with first metatarsophalangeal joint  (MPJ) osteoarthritis. The patient has failed conservative treatments including local steroid injections to symptomatic joint, anti-inflammatory medication, bracing, padding, modification of shoe gear, and modification of ambulation. The next logical step in this patients treatment would be custom orthotics with a Mortons extension to reduce the painful motion to the first MPJ. Orthotics have been used to treat first MPJ osteoarthritis for many years and is considered standard of care for this ailment. In this case, the shoe inserts received were medically necessary for this patients medical condition.  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 podiatry 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 an Afirma Thyroid FNA Analysis test for evaluation of her medical condition.  Findings: Two physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  A relatively new test, Afirma Thyroid FNA Analysis, utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, Afirma Thyroid FNA Analysis test was likely to have been superior over other methods of evaluating this patient.  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:  One reviewer is board certified in internal medicine and is actively practicing. Two reviewers are  board certified in internal medicine with sub-specialty certification in endocrinology 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 an implantable occipital nerve stimulator for the treatment of her medical condition. Findings: Two physician reviewers found that the records indicate a diagnosis consistent with chronic migraine, as well as multiple other diagnoses. The patient appears to have tried multiple oral migraine preventives, including anti-seizure and antidepressant medications. Nerve stimulators, including occipital and trigeminal territory electrodes, appear promising in existing and ongoing studies for chronic headache, including chronic migraine. However, study results are inconsistent, with some studies showing no benefit to stimulation. The records do not indicate that she has been treated with Botox, which is proven to be beneficial for chronic migraine. Therefore, the superior efficacy of the requested implantable occipital nerve stimulator has not been established. Final Result: Two reviewers determined that the requested device 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 board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested separate anesthesia services during a colonoscopy for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the services at issue. Monitored anesthesia care (MAC) services were not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. According to the documentation submitted for review, there were no specific circumstances in this case that warranted MAC anesthesia. In this case, the patient could have been sedated by the gastroenterologist using a short-acting narcotic and benzodiazepine. Based on the documentation submitted for review and the peer-reviewed literature, the services at issue 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 internal medicine with sub-specialty 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 residential mental health treatment for the treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the treatment intervention, as the record fails to demonstrate that less restrictive interventions targeting his substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  Upon admission, he had stable vital signs and an unremarkable mental status examination.  There was no evidence of significant medical or psychiatric comorbidity, and the patient was motivated.  Further, the record did not include critical documents from the treatment facility.  In the absence of such clinical documentation, there is no evidence to suggest that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming in a sober living environment, would have been unreasonable or consistent with inadequate care.  Thus, residential treatment center services were not medically necessary for the treatment of this patient.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an endobronchial valve device placed for treatment of her medical condition.  Findings:  Two physician reviewers found that the use of endobronchial valve device has shown to be safe in the medical literature. Researchers studied the safety and effectiveness of bronchial valves for the treatment of severe emphysema. The results confirmed an improvement in the quality of life scores and treated lobes decreased in size from baseline. In addition, another research study included 220 patients randomized to an endobronchial valve or standard medical therapy. The study noted improvements with forced expiratory volume in 1 second (FEV1) increase and walking distance. More relevant to this case was the identification of a subset of patients who did very well. The differentiation was the degree of lung heterogeneity present. When all the lung tissue was emphysematous, results were poor.  When some of the lung was free of disease results were much better. The meta-analysis concluded that there was documentation of statistically significant improvement in FEV1, dyspnea score, cycle ergometry and walking distance. In this case, endobronchial valve device placed was likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   One reviewer is board certified in internal medicine and pulmonary disease and is actively practicing. Two reviewers are board certified in general surgery and thoracic surgery with sub-specialty certification in vascular surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his 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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97%.  Per guidelines, the patient is ineligible for alternative regimens, which require interferon, due to the presence of possible immune-mediated disease. In addition, delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer 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 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 Vicodin for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medication has not been established. The current standard of care for acute onset back pain is conservative therapy treatment to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy after failing a trial of conservative therapy. Researchers reported that high dose and short acting 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. The submitted records do not document the patient has failed conservative therapy. Based on the clinical documentation and peer-reviewed literature, the patients request for Vicodin is not medically necessary.  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 and 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 Harvoni for treatment of her 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.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  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.  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 Harvoni for treatment of her 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.  Per the 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.  Per the medical evidence, the requested treatment with Harvoni is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the LINX procedure for treatment of her medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System is used to augment the pressure of the lower esophageal sphincter.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies at four years are encouraging.  However, thus far, studies looking at the device have not included a control arm.  In addition, published reports have come from only a few centers.  At this time, the superior efficacy of the requested services has not been established.  Therefore, the requested LINX procedure is not likely to be more efficacious than other treatment options. Final Result: Three 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 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 Viekira Pak for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the 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 comorbid conditions regardless of fibrosis. According to the guidelines, patients taking a specific HIV medication should not be treated with Viekira Pak due to a drug interaction resulting in significant gastrointestinal and neurologic side effects.  Additionally, the guidelines state that Viekira Pak should be used with ribavirin when treating genotype 1a. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% . For these reasons, the requested Viekira Pak is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a referral with a bariatric surgeon and bariatric revision surgery for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Weight regain following gastric bypass surgery is often behavioral, and the success rates of revisional surgery are variable.  The durability of weight loss is not known.  There is a lack of support for the requested services in this clinical setting.  The records do not demonstrate a concerted attempt at nonsurgical weight loss prior to the requested revisional surgery.  Additionally, records reflecting long-term follow-up with her bariatric program and an aftercare program were not provided.  An evaluation for surgically correctable causes of weight regain should include an upper gastrointestinal series.  Based upon the medical records, the requested referral with a bariatric surgeon and bariatric revision surgery are 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 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.