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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Forteo for treatment of her medical condition.  Findings:  The physician reviewer found that Forteo (teriparatide) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and nonvertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. These results are superior to other osteoporotic agents available.  Studies show that teriparatide was well tolerated with significantly greater increases in lumbar spine bone mineral density (BMD) from baseline compared with placebo, antiresorptive agents, or elcatonin/calcitonin. The sequence of therapy is important, especially in patients with severe bone loss. It has been demonstrated that the use of an antiresorptive agents such as bisphosphonate or denosumab prior to teriparatide decreases the beneficial metabolic effect of teriparatide on bone density. Alendronate reduces the ability of teriparatide to increase BMD and bone turnover in women. In postmenopausal osteoporotic women switching from teriparatide to denosumab, bone mineral density continued to increase, whereas switching from denosumab to teriparatide results in progressive or transient bone loss. These results should be considered when choosing the initial and subsequent management of postmenopausal osteoporotic patients. Given the above, teriparatide (Forteo) is medically necessary for this patient. It is best standard of care to prevent fractures and comorbidities by providing her the best therapy available. 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 endocrinology and metabolism 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 intravenous immune globulin (IVIG) for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. The treatment of specific antibody deficiency with replacement immunoglobulin, although U.S. Food and Drug Administration approved, is controversial. Although there have been recurrent infections, there is no supporting documentation, such as chest CT, sinus CT or antibiotic log to confirm recurrent infections. The patient has not been vaccinated with the conjugate pneumococcal vaccines. There also is no documentation of a trial of prophylactic antibiotics. In sum, the records do not support a diagnosis of CVID.  Therefore, the use of IVIG is not medically necessary for treatment of the 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 internal medicine, allergy and immunology and rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of his 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.  For patients with hepatitis C, genotype 2 infection who are interferon-ineligible and have had failed therapy with Sovaldi and ribavirin, the guidelines recommended Sovaldi/Daklinza with or without ribavirin for 24 weeks.  For these reasons, the requested treatment with Sovaldi and Daklinza is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted by a researcher, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Researchers also reported that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested lumbar sympathectomy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  There is a lack of other options other than the lumbar sympathectomy in this patients case.  Per the medical evidence, a lumbar sympathectomy is the best surgical treatment option. This patient has failed treatment with medication, and he continues to have symptoms which affect his quality of life.  In sum, the requested lumbar sympathectomy is likely to be of greater benefit than other treatment options. Final Result: Two reviewers determined that the requested services are 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:  All three reviewers are board certified in 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 Xifaxan for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Xifaxan is being requested to treat bacterial overgrowth.  This indication has been studied, and Xifaxan has proven highly effective for eradication of bacteria and for symptom relief in randomized and retrospective studies at high dose. The medication had greater effectiveness with fewer side effects than alternatives.  Per the medical evidence, results are sustained for several weeks after treatment.  Xifaxan treatment has also proven to alleviate symptoms in patients with irritable bowel syndrome with positive breath test for bacterial overgrowth.  All told, Xifaxan 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a wearable cardioverter defibrillator for treatment of his medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presented with newly diagnosed non-ischemic cardiomyopathy. In this case, initially the utilization of the wearable cardioverter defibrillator was not indicated as the patient did not meet criteria for implantable cardioverter-defibrillator (ICD) deployment. The peer-reviewed literature does not demonstrate an improvement in outcomes with the deployment of the wearable cardioverter defibrillator in the setting of newly diagnosed non-ischemic cardiomyopathy. However, subsequently, the wearable cardioverter defibrillator was medically necessary because the patient had met the criteria for ICD placement. Thus, the wearable cardioverter defibrillator was medically necessary at this point; but not before.Final Result: The reviewer determined that a portion of the services at issue were 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 and 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C.   Findings:  The physician reviewer found that according to 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 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.  For these reasons, the requested treatment with Sovaldi and Daklinza is 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 Zohydro ER for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers 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.  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.  High-dose opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Zohydro ER 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 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

Nature of Statutory Criteria/Case Summary: An enrollee has requested sclerotherapy 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.  The current medical evidence does not support sclerotherapy in this clinical setting.  This patients records indicate that she has spider veins, and there are only specific situations where sclerotherapy for spider veins is medically indicated.  The submitted documentation does not demonstrate how treating these veins would help with her symptoms.  All told, sclerotherapy is 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 vascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested speech therapy for treatment of her medical condition.  Findings:  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The services at issue are supported by the medical literature in this clinical setting. Researchers assessed the effectiveness of speech and language therapy (SLT) for aphasia following stroke. They concluded Our review provides some evidence of the effectiveness of SLT for people with aphasia following stroke in terms of improved functional communication, receptive and expressive language. Based on this review SLT appears to have efficacy in the treatment of aphasia secondary to stroke. In this case, the patient has shown improvement with speech and language therapy. As such, speech therapy 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:   All three reviewers are board certified in physical medicine and rehabilitation 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:  The parent of an enrollee has requested partial hospitalization level of care behavioral health services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that partial hospitalization level of care behavioral health services was medically necessary. The American Psychiatric Association (APA) guidelines for the treatment of eating disorders states Patients need to both gain healthy body weight and learn to maintain that weight prior to discharge; patients who reach a healthy body weight but are discharged before this learning occurs are likely to immediately decreased their caloric intake to excessively low levels that are often insufficient to sustain their healthy body weight. Based on the documentation submitted for review, the statement above describes the situation of this patient. According to the APA guidelines, PHP level of care was indicated as she had only partial motivation to recover and was preoccupied with intrusive, repetitive thoughts. She also needed structure to gain weight. Therefore, the treatment at the partial hospitalization level of care was medically necessary for treatment of the 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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intralesional corticosteroid injections for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to the documentation submitted for review, the patient presents with chronic plaque psoriasis and has been treated with intralesional corticosteroid injections which has reportedly been effective. Psoriasis is a chronic inflammatory condition involving thickened scaly plaques on extensor regions of the skin. Treatment of psoriasis often involves topical or intralesional steroids, topical vitamin D or systemic immunosuppressants. In this case, the request for intralesional injections is medically necessary as this has been effective for the patient and is considered to be a first-line therapy. Therefore, intralesional corticosteroid injections are medically indicated for this patient. 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 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:  The parent of an enrollee has requested eye movement desensitization and reprocessing (EMDR) therapy for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with autism spectrum disorder, speech/language disorder and academic difficulties. The requested services are not clinically indicated in this clinical setting. EMDR therapy is a therapeutic technique that only has utility in treating individuals diagnosed with PTSD. The documentation submitted for review does not demonstrate a diagnosis of PTSD. In this clinical setting, the peer-reviewed literature recommends behavioral interventions such as ABA therapy, which this patient is currently receiving. For the reasons provided above, the request for EMDR therapy is not indicated for 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 psychiatry with sub-specialty certification in child and adolescent 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.