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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sofosbuvir and simeprevir for treatment of his hepatitis C virus.  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The AASLD/IDSA guidelines recommend treatment with sofosbuvir and simeprevir for 12 weeks in genotype 1b hepatitis C patients without cirrhosis, as a Class I, Level A recommendation. This is based on the U.S. Food and Drug Administration (FDA) approval and multiple studies, which have confirmed its safety and efficacy. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, sofosbuvir and simeprevir are medically necessary in this patients case. Final Result: Two reviewers 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:  One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 orthoptic training for treatment of the enrollees convergence insufficiency. The physician review found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. Convergence insufficiency is under the broad category of vergence dysfunction. Evidence-based research demonstrates that orthoptic training has a high success rate in the treatment and management of vergence dysfunction. Office-based orthoptic training has been shown to have the greatest impact on improving the fusional ranges of patients with convergence insufficiency. In-office therapy has also been shown to be more effective than either prescribed computerized home therapy or pencil push-ups alone. For these reasons, orthoptic training was medically necessary for the treatment and management of the patients convergence insufficiency. 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 optometry 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 requested Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The medical literature supports the requested medication for the treatment of this patient.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested morphine and Soma for treatment of his chronic pain.  Findings:  The physician reviewer found that the requested medications are not medically necessary. Such narcotics and at the doses prescribed is presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. The medical literature reported that high dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold, and potentially mask 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. The medical literature reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The medical literature also reported that carisoprodol treatment resulted in tolerance and antagonist-precipitated withdrawal, suggesting it may have an addiction potential similar to that of other long acting benzodiazepine or barbiturate compounds. This patient has been on the requested medications for a significant period of time without documentation of improved function or attempted weaning. The 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. Opiates are considered adjunctive to this therapy and require close monitoring by a certified pain management physician. It is in this patients best interest to wean down or off all opiates and participate in adjunctive therapy including non-narcotic medications, physical therapy, massage therapy, or cognitive behavioral therapy, in order to address the chronic pain.Final Result: The reviewer determined that the requested medications 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 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:   The parent of an enrollee has requested speech therapy, one time per week for 60 minutes, for treatment of the enrollees developmental language delay.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested therapy.  The patient had considerable delays in both receptive and expressive language.  Based upon the submitted evaluations, she has gone from demonstrating moderate delays to above average language.  However, this would be difficult to achieve.  Of note, the speech therapy goals included following two-step unrelated directions without gesturing, which is not a typical goal for a patient with above average language skills.  Given the clinical documentation, an updated evaluation with another method of testing is needed in order to establish the medical necessity of the requested speech therapy.  The evaluation for articulation problems may be difficult.  The records document concerns regarding conversational language and language with peers.  All told, the requested speech therapy, one time per week for 60 minutes is not medically necessary for the treatment of this patient based upon the information provided at this time.  Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental-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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested oxycodone APAP for treatment of his chronic knee pain, osteoarthritis, and lumbar spine degenerative disc disease. The physician reviewer found that the available medical records provided for review do not support a continuation of opioids for this patient. The medical records demonstrate high risk behavior for adverse event which constitutes a potential safety issue. Moreover, combination with alcohol is a relative contraindication for opioid therapy. Provenzano and Viscusi noted that opioids exhibit a well-established abuse potential and evidence supporting the efficacy of opioids in chronic pain management is limited. In addition, opioid exposure is associated with adverse effects on multiple organ systems. Cheung and colleagues found that multiple current published guidelines suggest that opioid use should be limited in patients that demonstrate high risk behavior including failure to follow opioid consent agreements, aberrant use of opioids or concomitant use of alcohol. Nuckols and colleagues reported that recent guidelines on chronic pain agree on several opioid risk mitigation strategies, including upper dosing thresholds, caution with certain medications, attention to drug-drug and drug-disease interactions, and use of risk assessment tools, treatment agreements, and urine drug testing. All told, the medical records do not support the medical necessity of the requested oxycodone APAP for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in neurology 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 inpatient hospital admission for treatment of his chest pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient presented with chest discomfort concerning for possible coronary ischemia but normal cardiovascular physical examination, normal electrocardiogram and normal cardiac troponin.  In this circumstance of a clinically stable patient with an initial negative evaluation, it would have been medically appropriate to manage the patient at an observational level of care as opposed to a hospital admission.  Based on the patients initial presentation, it would have been reasonable to anticipate the patients hospital length of stay would not exceed 24 hours.  The current medical evidence does not support the services at issue in this clinical setting.  All told, inpatient hospital admission was not medically indicated for the treatment of this patient.  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 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 a thigh lift for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not include documentation of infections in the thigh folds, or photographs documenting cellulitis, ulcerations or rashes.  The patient reports a history of thigh infections, but problems with thigh infections are not mentioned in the primary care physician notes provided for review.  The medical records do not provide documentation in the form of frequent physician visits for the management of ongoing clinically significant dermatologic problems that have either never responded to topical therapy given or despite initial response, have recurred and caused significant functional impairment.  Surgical lipectomy should be reserved for patients that have failed optimal medical management for intertrigo, which is not the case for this patient.  The clinical notes do not provide sufficient documentation to confirm the failure of medically supervised care.  Additionally, the patients condition does not constitute an abnormal structure of the body.  The patient has excess thigh skin, which is an anticipated outcome following weight loss.  All told, the requested thigh lift is not reconstructive in nature and is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested services are not reconstructive in nature and 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 plastic 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 the wound product Oasis for treatment of his medical condition.   Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  This patient presented with a non-healing venous stasis ulcer of the left lower extremity.  Mostow and colleagues reported a multicenter randomized, controlled trial of standard care compared to the Oasis wound matrix and noted an improved healing rate as well as a durable healing.  The comprehensive data on wound matrices for the treatment of venous stasis ulcers when combined with debridement and compression demonstrate efficacy for improved and durable healing of the ulcers.  All told, the wound product Oasis was likely to have been superior over other treatment options.  Final Result: Three 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested transcatheter valve repair of mitral regurgitation for treatment of his medical condition.   Three physician reviewers found that this patient had both symptoms and objective findings supportive of severe mitral regurgitation.  In addition, there is documentation that that patient had prohibitively high surgical risk due to severe left ventricular dysfunction.  Valve morphology on echocardiography was determined to be suitable for percutaneous valve repair using MitraClip device.  In this circumstance, percutaneous valve repair has shown to be a safe and effective alternative compared to open surgical repair for reducing mitral regurgitation.  There is sufficient support for percutaneous repair with MitraClip for patients with prohibitively high-risk for open surgical repair and suitable valve morphology.  Therefore, transcatheter valve repair of mitral regurgitation was likely to have been superior over other treatment options.  Final Result:  Three 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: One reviewer is board certified in internal medicine with sub-specialty certification in interventional cardiology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 a consultation with a neurosurgeon for treatment of the enrollees neck mass.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has chronic neck pain and a neck mass.  The Health Plan has recommended a consultation with an ear, nose and throat specialist.  However, an ear, nose and throat specialist reportedly referred the patient to pain management.  The neck mass is located in the upper posterior neck.  Ear, nose and throat specialists are generally involved with the treatment of anterior neck lumps.  In this patients case, given the location of the mass, evaluation and treatment by a neurosurgeon is medically appropriate.  Due to the patients posterior neck pain and a mass at level of C2, a neurosurgical referral is standard of care.  All told, the requested consultation with a neurosurgeon is medically necessary for the 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 neurological 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 a 12 week course of Harvoni for treatment of her chronic hepatitis C virus genotype 1a. Findings: Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. Per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Therefore, although Harvoni is clinically appropriate in this setting, the requested duration of 12 weeks of therapy is not medically necessary given that the patient is treatment-naive and has a viral load of less than 6 million IU/mL. As such, the requested 12 week course of Harvoni is not medically necessary. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested Rituxan for treatment of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested medication in this clinical setting.  Per the medical records, this patient has been diagnosed with peripheral nerve vasculitis (mononeuritis multiplex).  She has not responded to a trial of standard therapy medications.  The medical literature does not support treatment with Rituxan in this patients case.  Rituxan has not been proven to be safe and effective for the treatment of peripheral nerve vasculitis, mononeuritis multiplex.  There are other therapies with established efficacy available in this setting.  Therefore, Rituxan is not likely to be more effective than other treatment options. Final Result: Two reviewers determined that the requested medication 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in 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.