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 for Viekira XR, one tablet twice daily for a duration of 12 weeks. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies regardless of fibrosis. Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira XR for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety. The medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The guidelines also cite data showing increased survival with earlier treatment. For these reasons, Viekira XR, one tablet twice daily for a duration of 12 weeks 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg one tablet daily for 12 weeks.  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), regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50/100 mg one tablet daily for 12 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 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 acupuncture. Findings:  The physician reviewer found that although there is some peer-reviewed literature supporting a trial of acupuncture for chronic lower back pain, other articles reported the effectiveness of acupuncture for lower back pain remains unclear (van Tulder, et al; Cherkin, et al). Moreover, the use of acupuncture for the treatment of carpal tunnel is not supported in the peer-reviewed literature (OConnor, et al). In this case, the records submitted for review do not show evidence of objective functional improvement obtained with previous acupuncture sessions. The documentation does not include the specific gains obtained. 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 oriental 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 Olysio 150 mg and Sovaldi 400 mg with ribavirin 600 mg for duration of 24 weeks. 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), Deferral of treatment is recommended, pending availability of data for patients with HCV genotype 1, regardless of subtype, in whom previous treatment with any HCV nonstructural protein 5A (NS5A) inhibitors has failed, who do not have cirrhosis, and do not have reasons for urgent retreatment. This patients records do not document the presence of cirrhosis, and no other reason for urgent re-treatment compatible with the guidelines is provided. For these reasons, the requested treatment with Olysio 150 mg and Sovaldi 400 mg with ribavirin 600 mg for duration of 24 weeks is not supported as medically necessary for the re-treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested regimen 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Repatha 140 mg/mL Sureclick. Findings:  The physician reviewer found that based on the records provided, the patient has known coronary disease and suboptimal lipid control intolerant of multiple statin medications.  Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors, including Repatha, have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient meets these criteria since trying other medication classes that have proven efficacy, without sufficient results.  Repatha, in this clinical setting has shown to be safe and effective at lowering LDL cholesterol, and also have outcome improvement demonstrated in post hoc analysis of trial data to date. 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 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 Pazeo drops 0.7% 2.5 ml in 4 ml bottle. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this clinical setting. Olopatadine is a standard treatment for allergic conjunctivitis. It is both an antihistamine and also a mast cell stabilizer. It comes in three different concentrations: 0.1%, 0.2% and 0.7%. This patient was first prescribed a different drop, ketotifen, which was not effective. Next, he was prescribed the highest concentration of olopatadine (0.7%). However, there is no documentation that he has tried any other drops or that he had tried and failed the lower concentration olopatadine (0.1%) as a first step. As such, the documentation does not support using the higher concentration of olopatadine over the lower concentration of the medication. Therefore, Pazeo drops 0.7% 2.5 ml in 4 ml bottle is not medically necessary for the treatment of this patients eye condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients eye condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in ophthalmology 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 magnetic resonance imaging (MRI) of the knee. Findings:  The physician reviewer found that there is a lack of support in the medical literature for the requested services in this clinical setting. Studies found An MRI examination may be indicated if the patient has not responded to a trial of conservative treatment for 3-6 weeks. However, MRI alone has little to offer for patients with non-traumatic knee pain, no mechanical symptoms, and findings of degenerative arthritis on plain films.  Because the incidence of abnormal findings such as meniscal tears is high in asymptomatic patients, any MRI finding must be carefully correlated with clinical signs and symptoms.  Patients with persistent or recurrent unexplained pain after 3-6 weeks of conservative treatment may require MRI and may require referral to an orthopedist as a next step in the evaluation.  However, it should be noted that some orthopedic surgeons do not consider an MRI to be necessary before arthroscopic surgery or total knee replacement. This patient does not have a fracture based on previous diagnostic tests. The question of  when or whether to obtain an MRI of the knee, in the clinical setting of knee pain, is important. In this particular patient, his physical examination did not support a meniscal tear or a ligamentous injury or tear. Moreover, an orthopedic intervention was not recommended.  The only reason to obtain an imaging study is if it will change the course of treatment, and according to the records, this is not the case for this patient. The medical literature indicates that obtaining MRI without correlation with a detailed clinical examination can lead to unnecessary conclusions, and even worse, unnecessary surgery. For these reasons, the requested MRI of the knee is not medically necessary for evaluation of this patients medical condition. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for residential treatment program services. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself, nor was she a danger to others or gravely disabled.  She endorsed passive suicidal ideation, without plan or intent.  This was her baseline state over the many years prior to admission to this facility.  The staff noted her to be low risk for suicide.  Throughout her residential stay, progress was limited in that the predominant themes in her treatment revolved around the patients feelings of being dismissed, neglected, and persecuted by others.  Each month, she missed a number of scheduled therapy sessions. It was unclear if coping mechanisms for her underlying feelings of rage were being worked on or developed. The type and depth of psychotherapy was unclear, as progress reports were monthly and not individual in nature.  Similarly, physician progress notes were sparse.  The medical records do not support residential treatment level of care in this setting. She was struggling with feelings of persecution, dismissal, and alienation from those around her, specifically her family.  The ideal methodology for such patients is placement in a naturalistic setting (home environment) where such conflicts are readily evident and to work on them intensively in a dialectical behavior therapy style treatment, which is by nature outpatient.  All told, residential treatment program services from the date of service forward were not and are not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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 authorization and coverage for artificial disc replacement at C5-6 with Secure-C device. Findings:  The physician reviewers found that currently, there are adequate data to support the safety and effectiveness of the Secure-C artificial disc in well selected patients. Studies noted that the Secure-C artificial disc is U.S. Food and Drug Administration (FDA) approved and shows superiority in overall success in single level use. For treating symptomatic cervical disc disease, cervical disc arthroplasty is superior to anterior cervical discectomy and fusion in terms of overall, neck disability index, and neurological success. Furthermore, cervical disc arthroplasty is superior in terms of patient satisfaction, range of motion at the operative level, and secondary surgical procedures rate. For these reasons, the requested cervical disc arthroplasty at one level using the Secure-C implant is appropriate and likely to be of more benefit than any other standard surgical procedure for the patients medical condition. Final Result: 2 of 3 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 physician reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for supplemental oxygen and prospective authorization and coverage for an in-home sleep study. Findings:  The physician reviewer found that supplemental oxygen is used in the treatment of various clinical disorders, both respiratory and non-respiratory; relief hypoxia, treatment of pulmonary hypertension, polycythemia secondary to hypoxemia, chronic disease states complicated by anemia, cancer, migraine headaches, coronary artery disease, seizure disorders, sickle-cell crisis, and sleep apnea.  In this case, the documentation submitted for review does not support the need for supplemental oxygen.  The cardiac and respiratory examinations were unremarkable.  His oxygen saturation was 96%, and there was no documentation of abnormal laboratory studies or underlying comorbid conditions that would require oxygen.  Thus, the medical necessity for supplemental oxygen is not demonstrated.  The patient is requesting an in-home sleep study.  Home sleep apnea testing should only be used for the diagnostic evaluation of suspected obstructive sleep apnea in patients with a high pre-test probability of having moderate to severe obstructive sleep apnea and no comorbid medical or sleep disorders.  In this case, the patient has pulmonary fibrosis and paralysis of the left hemidiaphragm.  He does not meet criteria for in-home testing.  All told, the requested supplemental oxygen from the date of service in question forward was not and is not medically necessary for the treatment of this patient.  Additionally, the requested in-home sleep study is not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for evaluation and treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in internal 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 for the inpatient psychiatric hospitalization level of care services. Findings:  The physician reviewer found that, based on the available records, the inpatient psychiatric hospitalization level of care services provided during the dates of service in question were medically necessary for treatment of this patients medical condition. The progress notes indicate that the patient was cooperative in treatment and open to therapy. The patient did express suicidal ideation on one of the dates of service in question, but not after that date. The progress notes did not indicate self-harm behaviors but rather vague suicidal ideation. Due to the fact that the patient was no longer suicidal and was cooperative in treatment it appears that a less restrictive setting was appropriate. The functional impairment that the patient was struggling with was likely due to borderline personality disorder. One of the mainstays of treatment for borderline personality disorder is dialectical behavior therapy, which can occur in a less restrictive setting once patients are free from safety concerns. Inpatient treatment is considered the highest level of psychiatric care available. Medical necessity guidelines indicate that psychiatric symptoms must be severe and present to the degree that this level of care is needed. According to the patients score on the Level of Care Utilization System (LOCUS), the patient was a candidate for treatment with high intensity community based services. For these reasons, the inpatient psychiatric hospitalization level of care services provided during the dates of service in question were medically necessary. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50 mg  100 mg for 12 weeks. 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 regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. However, Zepatier is significantly less effective when NS5A resistance is present, and a different regimen is needed. This patients records do not include NS5A resistance testing results. Thus, although hepatitis C treatment is needed, treatment with Zepatier for 12 weeks 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 physician 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.