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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50mg /100 mg one tablet by mouth daily for 16 weeks for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (except those with limited life expectancy due to non-liver-related conditions). This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier with ribavirin for 16 weeks when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for a duration of 12 weeks when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, treatment is needed regardless of fibrosis stage. As such, the request for Zepatier 50 mg /100 mg one tablet by mouth daily for 16 weeks 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 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 authorization and coverage for cervical artificial disc replacement. Findings:  The physician reviewer found that evidence based medical guidelines and peer reviewed literature do not support the use of an artificial disc replacement adjacent to a prior anterior cervical discectomy and fusion and in the setting of multilevel degenerative disc disease. This patient presents with persistent neck pain radiating into the right upper extremity with constant numbness and tingling into the fingers. He has reported decreased right hand dexterity and functional difficulty in activities of daily living and recreational pursuits. This patient is status post mature fusion at the C5-6 and C6-7 levels. Clinical examination findings have evidenced sensory and motor loss and reflex changes consistent with imaging evidence of degenerative disc disease, severe at C4-5 and mild at C3-4, with severe neuroforaminal stenosis and cord contact at the C4-5 and C3-4 levels. Evidence of reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is a lack of long term large volume studies to support the superior efficacy of this procedure in the presence of apparent multilevel degenerative disc disease. Therefore, cervical artificial disc replacement is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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: Physician reviewers 1, 2, & 3 are board certified in orthopedic surgery 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 Saxenda 3 mg/0.5 ml (18 mg/3 ml) pen injector. Findings:  The physician reviewer found that The medical literature supports the requested medication in this clinical setting.  Saxenda has been approved by the U.S. Food and Drug Administration (FDA) for treatment of obesity. The medication is approved as an adjunct to a reduced calorie diet and increased physical activity for chronic weight management in adult patients with an initial BMI of 30 or greater.  The medication may also be appropriate as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus.  The patient has been diagnosed with morbid obesity, type 2 diabetes and dyslipidemia. Saxenda (liraglutide) is approved for the treatment of adults with BMI of at least 30 kg/m2 or a BMI of 27 kg/m2 if they had treated or untreated dyslipidemia, hypertension or prediabetes and was effective in weight loss in subjects without type 2 diabetes. While the documentation notes that the patient has not tried the formulary alternatives (sympathomimetic agents), there is not enough long term data on the safety of these drugs. Sympathomimetic drugs are not recommended for obesity management because of their potential side effects and short duration of use. This patient has a BMI greater than 57 kg/m2. As such, the requested authorization and coverage for Saxenda 3 mg/0.5 ml (18 mg/3 ml) pen injector is medically necessary for treatment of the patients medical condition.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 endocrinology, diabetes 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for skilled nursing care services to be provided 24-hours per day, seven days per week, at home; or 8-10 hours per day of skilled nursing services provided at home; or any skilled nursing services provided at home. Findings:  The physician reviewer found that custodial care is assistance with the activities of daily living that can be provided by a non-trained individual. This patients records indicate that she requires one hour of skilled nursing services provided at home per day, seven days per week. The skilled nursing services should include suctioning, assessment and ventilator management. However, feeding a patient via a feeding tube, turning the patient, grooming, bathing, and toileting are considered custodial services. Thus, one hour of skilled nursing care services provided at home are medically necessary for treatment of this 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 partially overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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 authorization and coverage for a custom quickie 2 ultralight wheelchair with smartchair accessories (E0986-manual wheelchair accessory, push activated power assist, each; K0005-ultralightweight wheelchair; E2218-manual wheelchair accessory, foam propulsion tire, any size, each; K0040-adjustable angle footplate, each; K0108-wheelchair component or accessory, not otherwise specified; E0973-wheelchair accessory, adjustable height, detachable armrest, complete assembly, each; E0971- manual wheelchair accessory, anti-tipping device, each; E1028-wheelchair accessory, manual swingaway, retractable or removable mounting hardware for joystick , other control interface or positioning accessory; E2606-positioning wheelchair seat cushion, width 22 inches or greater, any depth; and K0108-wheelchair component or accessory, not otherwise specified) for treatment of the enrollees Ehlers-Danlos syndrome. Findings:  The physician reviewer found that The documentation provided do not support the medical necessity of the requested equipment and accessories in this clinical setting. The records indicate that the patient has various symptoms and conditions, including fatigue and various pains.  The patient has had difficulty with ambulation at times. A scooter and a manual wheelchair with power assist have been recommended. The scooter has been declined by the patient/family due to accessibility issues within the home and transportation problems. The records, overall, do not indicate that the patients mobility related activities of daily living needs in the home could not be adequately met with a standard lightweight manual wheelchair under caregiver distant supervision. Notably, the patient is reported to have difficulty with prolonged sitting. The records do not support the medical necessity for the ultralight manual wheelchair with the accessories. Final Result: The reviewer determined that the requested equipment and accessories 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 physical medicine and rehabilitation 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 Orthovisc injections, one (1) per week, for three (3) weeks.Findings:  The physician reviewer found that the requested service is medically necessary for treatment of the patients medical condition. The peer-reviewed literature supports the use of hyaluronan therapy for treatment of the patients medical condition. A study concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. The medical literature support repeated cycles of viscosupplementation treatment to delay time to total knee replacement in patients with severe knee osteoarthritis who have failed conservative treatment, and state there is no maximum amount of injections established by high quality scientific evidence. In this case, the patient presents with recurrent right knee pain and swelling. The patient reports that the patient can barely walk or perform daily activities due to the pain and swelling. Clinical examination findings are consistent with radiographic evidence of severe tri-compartmental osteoarthritis of the right knee, with complete loss of the lateral joint space. Reasonable conservative treatment, including activity modification, medications, and corticosteroid injections, have failed to provide adequate relief. Prior viscosupplementation injections have provided complete pain relief and functional restoration for six months. The treating provider has recommended continued viscosupplementation injections to delay total knee replacement due to the young age of this patient. Therefore, the requested for hyaluronan/Deriv Orthovisc, for intra-articular injections per dose, one (1) per week, for three (3) weeks is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested service 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 orthopedic 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 authorization and coverage for left atrial appendage occlude implant procedure for treatment of the enrollees atrial fibrillation. Findings:  The physician reviewers found that this patient has a very high risk for bleeding on long-term anticoagulation. She has also had significant bleeding episodes in the past requiring transfusion and fistula surgery while on anticoagulation and needs to also be maintained on aspirin for coronary artery disease and prior drug eluting stents. She also has a high risk of embolic stroke. Given these competing issues, an alternative to long-term anticoagulation is reasonable to consider in this specific high risk clinical circumstance. The requested services have been shown to be efficacious in decreasing the risk of embolic stroke in patients with chronic atrial fibrillation. In this specific clinical scenario, in a patient with both high embolic stroke and high bleeding risk, the requested left atrial appendage occlude implant procedure is likely to be more effective than other treatment options. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone HCL solution. Findings:  The physician reviewer found that the stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings). It is unclear from the documentation provided as to why this patient is switching from a capsule to a solution despite no complication to the current medications. Nevertheless, in this case not all non-opioid treatment options have been utilized. There is no mention that this patient has completed behavior therapy despite much research to support its use. It is also reasonable to consider alternatives to opioids and to wean the patient to a lower dose of opioids or even off opioids. Furthermore, there is no objective treatment goals for pain and function noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. In addition, multiple minimal requirements for opioid prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain has not been established. Finally, not all non-opioid medications classes have been optimized or tried. For all these reasons, oxycodone HCL solution is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication solution 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 management 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 proton beam therapy (a type of radiation using a high-energy beam) for treatment of the enrollees prostate cancer. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested service. There is a lack of sufficient peer-reviewed clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of prostate cancer. Researchers evaluated the comparative effectiveness of intensity-modulated radiation therapy (IMRT), proton therapy, and conformal radiation therapy for prostate cancer. In the comparison between IMRT and proton therapy, IMRT patients had a lower rate of gastrointestinal morbidity. There were no other significant differences regarding toxicities between IMRT and proton therapy. In addition, the American Society of Radiation Oncologys (ASTRO) position statement on the use of proton beam therapy for prostate cancer state At the present time, ASTRO believes the comparative efficacy evidence of proton beam therapy with other prostate cancer treatments is still being developed, and thus the role of proton beam therapy for localized prostate cancer within the current availability of treatment options remains unclear. Final Result: The reviewer determined that the requested service 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 radiation oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Remicade infusions. Findings:  The physician reviewer found that the diagnosis of Crohns disease has been reasonably established in this case by colonoscopy results and consistent clinical symptoms. This patient has moderate to severe Crohns disease due to severity of symptoms and age at diagnosis. The American Gastroenterological Association (AGA) guidelines for induction of remission in moderate to severe disease recommend anti-tumor necrosis factor (TNF) inhibitors including Remicade. For maintenance of remission, treatment with TNF inhibitors are strongly recommended by these guidelines based on level 1 evidence. Uncontrolled disease flares can rapidly result in complications. Based on this patients records, she needs treatment expediently to treat an active disease flare and to avert complications of Crohns disease. Therefore, the request for Remicade infusions is supported as medically necessary for the treatment of the patients Crohns disease. 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: The parent of an enrollee has requested authorization and coverage for speech therapy for treatment of the enrollees mixed receptive-expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that according to research, ABA is effective for children with autism spectrum disorder. In this case, speech therapy is not clinically indicated at this time. According to the records provided, the patient lacks the behavioral and attention skills needed for speech therapy. At this time pre-language skills through ABA therapy is indicated for the patient to develop pre-linguistic skills. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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.