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 for the anesthesia services provided during an endoscopy for evaluation of the enrollees colitis and polyps. Findings:  The physician reviewer found that the records do not document that this patient meets the criteria for use of monitored anesthesia services during endoscopy. Specifically, there is no evidence that the patient has a contraindication to conscious sedation or is at high risk of a complication from the use of conscious sedation. Moreover, there is no rationale presented to support an indication for monitored anesthesia services for a routine surveillance endoscopy in lieu of conscious sedation. Therefore, the monitored anesthesia services provided during an endoscopy were not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 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 authorization and coverage for Epclusa 400-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C.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 in all cases, regardless of fibrosis stage. Per the guidelines, for genotype 3 patients (regardless of cirrhosis status) who have failed Sovaldi and ribavirin, therapy is recommended with Epclusa and ribavirin for 12 weeks. This recommendation is based on clinical study data showing lack of NS5B resistance after Sovaldi use. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: A parent of a five-year-old male enrollee has requested authorization and coverage for referral to cranial sacral osteopathy for treatment of the enrollees bilateral esotropia and hyperopia. Findings:  The physician reviewer found that there is currently a lack of peer-reviewed medical literature to support the beneficial effects of craniosacral therapy, especially on patients with ocular disorders. Clinical trials have failed to produce evidence of changes in coronal suture movement or intracranial pressure with craniosacral manipulation. Moreover, studies have attempted to evaluate examiner reliability for palpation of the cranial rhythmic impulse and concluded it was poor to nonexistent. Overall, there is a lack of evidence based studies to suggest that craniosacral therapy would improve this patients hyperopia or esotropia. Thus, the requested cranial sacral osteopathy is not supported as medically necessary for treatment of this patients medical condition. 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 osteopathy 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 Harvoni for 12 weeksfor 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 (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 1 patients, or those who have failed peg-interferon and ribavirin, 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 approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. Final Result: The reviewer determined that the requested medication regimen 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 authorization and coverage for Taltz for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. There is a lack of documentation that indicates that this patient has tried and failed methotrexate, cyclosporine, acitretin, Enbrel or Humira. The patient is BRCA2 positive, but the medical evidence does not show that use of Taltz over methotrexate, cyclosporine, acitretin, Enbrel or Humira confers any medical advantage.  The documentation of adverse effects or contraindication to the use of the methotrexate, cyclosporine, acitretin, Enbrel or Humira has not been documented in this patient. As such, Taltz is not medically necessary for the treatment of this patients medical condition. 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 dermatology 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  for treatment of the enrollees alcohol abuse. Findings:  The physician reviewer found that there was no evidence of post-acute withdrawal symptoms. The patient was not a danger to self or others. There were no emotional, behavioral, cognitive, or impulsive issues to warrant further RTC level of care services. The patient was not manic, psychotic, or agitated. The patient was medically stable. The patient declined medications for his anxiety and depressive symptoms. The patient had come to accept that he must remain abstinent, and was engaged in the recovery process. The patient was cooperative and compliant, his family was supportive, and he had a sponsor with whom to work. He no longer required the strict supervision provided by residential treatment, and could have been stepped down to an ambulatory setting such as partial hospitalization program (PHP) or intensive outpatient program (IOP) to continue his recovery.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 reimbursement and prospective authorization and coverage for continuous positive airwave pressure machine and equipment for treatment of the enrollees obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation demonstrates the medical necessity of the equipment at issue in this clinical setting. OSA is an increasingly prevalent clinical problem with significant effects on both personal and public health. The medical evidence and peer reviewed literature indicate that CPAP has excellent efficacy and low morbidity. Long-term adherence rates approach 50%. CPAP, at an effective setting and verified by attended polysomnography, is a standard treatment for OSA. This patient presented with snoring, waking up tired, and complaints of falling asleep during the day and waking at night. He had OSA verified by PSG. He was treated successfully with CPAP, and he should continue using CPAP to avoid untoward cardiac sequelae. For these reasons, the CPAP machine and equipment were and are medically necessary for this patient. Final Result: The reviewer determined that the equipment at issue was and 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 otolaryngology 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: A 42-year-old female enrollee has requested authorization and coverage for a chest (thorax) magnetic resonance imaging for evaluation of the enrollee, who is status post right-sided sternoclavicular joint separation. Findings:  The physician reviewer found that The sternum and sternoclavicular joints may be affected by any number of anatomic, post-traumatic, metabolic, neoplastic, and infectious processes. Abnormalities of this area have been studied by virtually every diagnostic modality, including plain radiography, various cross-sectional procedures, and nuclear medicine. Each of these processes will yield diagnostic information. However, in this patients case, the issue is whether an MRI will yield diagnostic information which will change the course of therapy.  Although the patient has pain, there is no indication or information submitted that would suggest that she has an infection that should be drained, or a neoplasm affecting the area that might require specific treatment.  She has no history of tumor.  Her symptoms are likely related to her trauma. Plain x-rays would be expected to show an element of degenerative change and may also reveal a displacement. MRI studies would similarly be expected to show findings. A computed tomography (CT) scan would also adequately demonstrate displacements and degenerative changes. Per the medical evidence, CT scans will generally provide better delineation of the bony structures.  It is unlikely that MRI will show anything that will change the therapy, which will likely be related to relieving symptoms.  In terms of the sternoclavicular joint, there are no clear advantages to MRI for this patient. All told, the requested chest (thorax) MRI is not medically necessary for the evaluation of this patient. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Xifaxan for treatment of the enrollees irritable bowel syndrome with diarrhea. Findings:  The physician reviewer found that the medical literature supports that Xifaxan has proven efficacy for the treatment of irritable bowel syndrome, diarrhea predominant. The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Moreover, there is data for safety and effectiveness of subsequent courses of Xifaxan, which continued to be effective.  The subsequent courses were just as effective and the effect had a similar duration.  The medication has been proven safe and effective in randomized placebo controlled trials for IBS-D (Xifaxan package insert). In the TARGET-3 trial of over 1,000 patients, Xifaxan proved effective with significant symptom improvement in irritable bowel syndrome. The patient has already attempted alternatives such as dicyclomine without success. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients irritable bowel syndrome, diarrhea predominant. 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 for Zepatier for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to 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 conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier, based on clinical trial results showing a 99% cure rate regardless of nonstructural protein 5A (NS5A) resistance. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees hypercholesterolemia. Findings:  The physician reviewer found that based on the records provided, this patient has increased coronary risk, including hyperlipidemia, but no symptoms or objective findings of obstructive coronary disease and no documentation to support a diagnosis of familial homozygous or heterozygous hyperlipidemia. These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a strong family history of coronary disease (younger than 50 years in second-degree relative or aged 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria. Repatha is a proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented clinical atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient does not fit any of those criteria. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting. 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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for gastric bypass revision surgery for treatment of the enrollees recurrent morbid obesity. Findings:  The physician reviewer found that this patient is an adult female with morbid obesity with a BMI of 37 and sleep apnea. The patient is status post LRYGBP with weight regain. Normal postoperative anatomy is demonstrated on UGI. The patient documents minimal follow up after bariatric surgery with interval records documenting history of suicidal ideation. The patient has had no updated dietary or behavioral evaluation and is requesting revision to duodenal switch for weight regain. Although this patient remains morbidly obese, consideration for reoperative bariatric surgery would begin with an updated multidisciplinary evaluation that would include psychological and dietary evaluations to ensure that she is aware of the potential increased risks of malnutrition and ensure she is mentally stable, aware, and committed to proceed with reoperative bariatric surgery at this time. The American Society for Metabolic and Bariatric Surgery standard guidelines recommend psychological and dietary evaluations prior to reoperative bariatric surgery. Therefore, the requested gastric bypass revision surgery is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in surgery with expertise in bariatric 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha for treatment of the enrollees mixed hyperlipidemia. Findings:  The physician reviewer found that the request for Repatha has not been established as medically necessary for treatment of the patients medical condition. Based on the records provided the patient is a male with hyperlipidemia and statin intolerance but no documented obstructive coronary disease. Repatha is a PCSK9 inhibitor studied in and approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. In this case, the patient does not fit any of those criteria. There is no documentation to support a history of familial hypercholesterolemia since this diagnosis requires elevated LDL cholesterol levels that significantly exceed 180 mg/dL in combination with physical exam findings, a strong family history of coronary disease and documented genetic defects related to cholesterol metabolism according to published criteria. PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.