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 weekly therapy appointments for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The records noted a history of generalized anxiety disorder and major depressive disorder, recurrent, moderate.  The patients medications included Lamictal and Klonopin. He has had past trials of Wellbutrin, Lexapro, Prozac, and Effexor XR, which he was unable to tolerate. The records document that the patients symptoms warrant a trial of weekly outpatient psychotherapy of three months duration.  His problems with irritability and maladaptive thoughts are primary symptoms that respond to cognitive behavioral therapy/mindfulness type of treatment. All told, weekly therapy appointments for three months are medically necessary for the treatment of this patient. Final Result: The reviewer determined that a portion of the requested services is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a female enrollee has requested reimbursement and prospective authorization and coverage for services offered by the Scoliosis Academy and Janzen and Janzen Health Center for treatment of the enrollees scoliosis. Findings:  2/3 of the physician reviewers found that there is sufficient support in the body of literature as well as the documentation provided for the services at issue in this clinical setting. The patient has shown significant improvements in the curvature following the treatments at the Scoliosis Academy and Janzen and Janzen Health Center. The current medical literature also supports the combined treatments of three dimensional bracing and Schroth physiotherapy exercises. The current conservative treatment plan resulted in objective functional improvements. There is a lack of alternative options available for treatment of this patient except for surgery and in this case, surgery is not recommended due to the patients age, medical, and physical condition. Accordingly, the services offered by the Scoliosis Academy and Janzen and Janzen Health Center were and are likely to be more effective than other modalities available for treatment of this patients medical condition. Final Result: 2/3 of the reviewers determined that the services at issue were and 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 reviewer number one is board certified in chiropractic care 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.Physician reviewer number two is board certified in chiropractic care 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.Physician reviewer number three is board certified in chiropractic care 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 reimbursement for posterior tibial neurostimulation for treatment of the enrollees urinary urgency. Findings:  The physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of posterior tibial neurostimulation in patients with urinary urgency and frequency, as in this case. However, most trials have a small number of patients with short term follow-up. American Urological Association guidelines recommend that clinicians should offer behavioral therapies, such as bladder training, bladder control strategies, pelvic floor muscle training and fluid management, as first-line therapy to all patients with overactive bladder. Behavioral therapies may be combined with pharmacologic management. Clinicians should offer oral anti-muscarinics or oral beta 3-adrenoceptor agonists as second-line therapy. If a patient experiences inadequate symptom control and/or unacceptable adverse drug events with one anti-muscarinic medication, then a dose modification or a different anti-muscarinic medication or a beta 3-adrenoceptor agonist may be tried. Patients who are refractory to behavioral and pharmacologic therapy should be evaluated by an appropriate specialist if they desire additional therapy. The guidelines rate posterior tibial neurostimulation as a recommended third-line therapy. In this patients case, the documentation does not support the use of less invasive second-line therapies.  Therefore, the superior efficacy of posterior tibial neurostimulation has not been established.  Final Result: 2/3 reviewers determined that the services at issue were 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 reviewer number one is board certified in urology 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.Physician reviewer number two is board certified in urology 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.Physician reviewer number three is board certified in urology 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 long term care for treatment of the enrollee who has a history of acute gastric ulcer with hemorrhage, heart failure and hypertension. Findings:  The physician reviewer found that according to the medical literature and guidelines, a patient qualifies for prolonged care at a long term care facility if they have debilitating conditions including extreme age, which indicate a need for preventive nursing care and supervision to avoid skin breakdown, fractured bones, nutritional deficiency or infectious conditions. In this patients case, the documentation supports that the patient appears to have been losing weight.  Moreover, she has congestive heart failure with venous stasis ulcers that require intermittent adjustments in diuretic medications and antibiotics.  She has had multiple complications including a bleeding stomach ulcer and possible infection with C. diff.  The patient is at an advanced age of 88 and appears to be requiring more care than previous for medical problems. She requires a multidisciplinary approach to prevent further decline with weight loss, falls, infections requiring antibiotics and decompensations of heart failure with recurrent venous stasis ulcers of the lower extremities.  The documentation supports the medical necessity for custodial care at a long term care facility in this case. Therefore, long term care is medically necessary for treatment of 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 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 right hip arthroscopy with arthroscopically assisted labral repair, pincer osteoplasty, and CAM osteoplasty provided for her treatment of hip pain.  Findings: The physician reviewer found that current peer reviewed literature supports surgical management of femoroacetabular impingement syndrome when nonsurgical treatment methods fail. Hellman and colleagues reviewed five approaches for surgical management of femoroacetabular impingement syndrome, including arthroscopy. They reported that femoroacetabular impingement was a common pathologic disorder of the hip that caused pain and had been implicated in the development of early osteoarthritis in young adults. Harris and colleagues concluded that the outcomes of operative treatment of femoroacetabular impingement are significantly better than nonsurgical management. Surgical treatment significantly improved outcomes, with no consistent significant differences exhibited between open and arthroscopic techniques. This patient presented with a history of progressively worsening and functionally limiting right hip pain for more than one year. She had associated mechanical symptoms, including locking and clicking. Clinical examination findings were consistent with imaging evidence of labral separation and femoroacetabular impingement syndrome. She failed over one year of conservative treatment including activity modification, ice, and anti-inflammatory medications. Therefore, right hip arthroscopy with arthroscopically assisted labral repair, pincer osteoplasty, and CAM osteoplasty provided was medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the inpatient hospital stay for treatment of his bladder tumor. Findings: The physician reviewer found that noted in the medical literature, the majority of patients who undergo transurethral resection of bladder tumor can be discharged either on an ambulatory basis or within 24-hours of the procedure. This patients procedure was an elective, scheduled procedure. The patient did not have any significant risk factors which would have increased the risk of post-operative complications. His post-operative course was essentially normal without any significant complications other than minor issues with pain control. Observation status for this patients clinical presentation and post-operative course was the safe, effective, generally accepted standard and the most appropriate treatment option. Thus, the inpatient hospital stay was not medically necessary for treatment of this patients bladder cancer. 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 urology 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 Tradjenta for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that Diabetes is a progressive disease, which typically manifests with increasing loss of glycemic control over time despite lifestyle and pharmacologic intervention.  Although type 2 diabetes is initially due to insulin resistance, studies have shown that patients with this disease also may have a decline in pancreatic beta cell function, which begins as early as 12 years before diagnosis and continues throughout the disease process.  Many clinicians now recognize the importance of avoiding prolonged hyperglycemia in patients with short diabetes duration in order to minimize its impact on decline of beta cell function and its potential effect on late microvascular and macrovascular complications.  A number of new diabetic medications have been developed recently which are frequently being used earlier in the course of treatment of diabetes.  Among these is the DPP4 inhibitors (DPP4i), such as Tradjenta, which are a class of newly developed antidiabetic drugs which help lower blood glucose levels and may help preserve pancreatic beta cell function.  While all of the members of the DPP4i class of medications appear to be efficacious for the treatment of diabetes, a potential advantage of Tradjenta over the other drugs of its class is that it is not extensively renally excreted, and it is instead eliminated primarily via the hepatic route. The Health Plan has offered coverage for renal dose-adjusted alogliptin as an alternative. However, even low dose alogliptin is excreted by the kidneys. Tradjenta appears to be preferable over the other members of its class for the treatment of diabetes in the presence of renal impairment. All told, Tradjenta is medically necessary for 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for treatment of the enrollees hepatitis C virus. 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. 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 when NS5A resistance is not found, and Zepatier with ribavirin when NS5A resistance is present. These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier when NS5A resistance is present. When NS5A resistance is present, Zepatier and ribavirin is recommended by the guidelines, based on a 100% cure rate in the C-EDGE TE trial.  In this case, as NS5A resistance testing results are not provided, it is impossible to determine whether the requested regimen is appropriate. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, although treatment is needed regardless of fibrosis stage, the request for Zepatier is not supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a seven-year-old female enrollee has requested authorization and coverage for growth hormone therapy with Genotropin (somatropin) for treatment of the enrollee's idiopathic short stature.Findings:  The physician reviewer found that the request for growth hormone therapy with Genotropin (somatropin) is medically necessary for treatment of the patients medical condition. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. In this case, the patient meets most of the above criteria. The patients height is more than 3 SDs delayed, her growth velocity is poor, and her bone age is markedly delayed. In addition, with normal growth factors, GH stimulation testing is not indicated, as the patient is not likely to have classic GH deficiency. The patient meets standard U.S. Food and Drug Administration (FDA) criteria for a trial of GH for treatment of idiopathic short stature.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 pediatrics with sub-specialty certification in pediatric endocrinology 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 Maxalt for treatment of her migraines. Findings: The physician reviewer found that the medical records provided for review document headache frequency, severity, and associated symptoms consistent with a diagnosis of migraine headache. The current peer-reviewed medical literature supports Maxalt for abortive treatment of migraine headaches. Maxalt has been approved by the U.S. Food and Drug Administration (FDA) for abortive treatment of migraine headache (Becker; Kassem). Moreover, Maxalt is approved for use up to two times per week. Given this support, the requested Maxalt is medically necessary for treatment of this patients migraine headaches. 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 neurology 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 Belsomra 10 mg for treatment of the enrollees insomnia.Findings:  The physician reviewer found that there is a lack of documentation that Belsomra is superior to other medications that are also U.S. Food and Drug Administration (FDA) approved for the treatment of insomnia including Zolpidem, Zolpidem extended release, Lunesta, and Sonata. This patients records do not document an adequate trial and failure, or contraindication to treatment with these standard first-line therapies. Moreover, Belsomra is not FDA approved for the treatment of PTSD. 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 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.