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

Nature of Statutory Criteria/Case Summary: An enrollee has requested retroactive authorization and coverage of residential treatment or partial hospitalization services for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that although comprehensive chemical dependency services are indicated, the record does not support the request for services at either the residential or partial hospital levels of care.  The treatment facility projected a treatment course of 30 days.  The record indicates that the patient enjoyed steady therapeutic gains during the admission.  The patient was reconciling her guilt and unresolved bereavement, and exploring barriers to effective communication within her family.  The patient was progressing well and was motivated to make meaningful lifestyle changes.  The patient continued to address the issues that triggered her alcohol use, such as her difficulty with self-assertion, feelings of shame and guilt, and strained relations with a family member.   The record indicates that the patient improved with treatment, the duration of which aligned with community standards.  There was no interpretative summary or treatment plan update indicating why the level of care remained necessary after a month.  Further, she was sober and tolerating appropriate pharmacotherapy in the absence of psychiatric distress or an unstable medical condition.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been unsafe or inadequate.  All told, the requested residential treatment or partial hospitalization services are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Epclusa 400mg/100mg, one tablet daily for 12 weeks.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. Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin.  Delay in treatment may result in decreased survival. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested gene test (Foundation One) for evaluation of the enrollees colon cancer.  Findings: Two physician reviewers found that according to the National Comprehensive Cancer Network (NCCN) guidelines for colon cancer, testing for mutation in the KRAS, NRAS and BRAF genes are advised for metastatic disease to determine efficacy of EGFR inhibitors such as Vectibix and Erbitux. However, all other mutations are not necessary to determine treatment. In this clinical setting, the testing for KRAS, BRAF and NRAS was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Overturned Decision of Health Plan

An enrollee has requested reimbursement for digital breast tomosynthesis that was performed. Findings:  The physician reviewer found that the patient reported a family history of breast cancer with a paternal aunt who was diagnosed. The recent study was compared to prior studies. The patients breast tissue was described as average. There was no mammographic evidence of malignancy. The impression was benign, BI-RADS 2. The Health Plan has denied the reimbursement for the digital breast tomosynthesis performed. The Health Plan denied the service at issue as investigational for the evaluation of this patient.  Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewers are board certified in diagnostic radiology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for cardiac defibrillator implantation for treatment of the enrollees hypertrophic cardiomyopathy. Findings:  The 3 physician reviewers found that this patient presents with a history of hypertrophic cardiomyopathy and symptomatic non-sustained ventricular tachycardia. In this circumstance, accepted criteria for prophylactic defibrillator placement include the presence of at least two clinical risk factors. These factors include unexplained syncope, non-sustained ventricular tachycardia, family history of sudden death in a first degree relative, abnormal blood pressure response to exercise and left ventricular wall thickness greater than 30 mm. In addition, most guidelines suggest that in circumstances of uncertainty such as the presence of only one risk factor, that the identification of late gadolinium enhancement by cardiac magnetic resonance indicative of myocardial fibrosis or marked left ventricular outflow tract obstruction at rest can be used to help aid decision-making on an individual basis. Since this patient has both non-sustained ventricular tachycardia and myocardial fibrosis by cardiac MRI, the requested cardiac defibrillator implantation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested service is 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 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.Physician reviewer number two 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.Physician reviewer number three 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 Harvoni for treatment of the enrollees hepatitis C virus.  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 except those with limited life expectancy due to non-liver-related conditions. The guidelines also recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. The U.S. Food and Drug Administration (FDA) prescribing information reports that a patients ALT may rise over five times the upper limit of normal in 1% of patients during Zepatier therapy, and discontinuation can be considered if the rise is greater than 10 times the upper limit of normal. However, elevated ALT at baseline is not a contraindication to Zepatier, per highlights of prescribing information. For these reasons, Harvoni for eight 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 regimen, without trial and failure of Zepatier, 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Butrans patches for treatment of the enrollees chronic pain. Findings: The physician reviewer found that in the documentation available for review, not all non-opioid treatment options have been utilized. Behavior therapy has not been provided despite much research to support its use (Lee, et al; Flor). Instead, large doses of opioids are being used, with a daily morphine equivalent (MEQ) dose that exceeds 120 MEQ despite research showing the dangers of such high dosing (Moulin, et al). In addition, the Centers for Disease Control and Prevention (CDC) recommends against use of this level of MEQ, not prescribing opioids with benzodiazepines, use of urine drug screens, using state prescription monitoring programs, and avoiding long acting opioids (Dowell, et al). Given the patients history of addiction to opioids, being on benzodiazepines, and overuse of prescription opioids, any continuation of opioids should be under the direct guidance of a mental health professional (Blasco-Fontecilla, et al). All told, the requested Butrans patches are not medically necessary for treatment of the 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested direct applied behavioral analysis (ABA) therapy (0365T) and oversight (0369T) for treatment of autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. The review by Reichow and colleagues shows that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. Based on the documentation submitted for review, this patient has appropriately received a high level of ABA therapy for four years. The therapy received has been effective in teaching him skills including communication, play skills and adaptive skills. He continues to have relational difficulties, refusal and difficulty with stress management. He does not have any particularly difficult maladaptive behaviors. Based on the patients progress and level of maladaptive behaviors, a reduction of ABA hours is indicated. However, the Health Plans authorization of 20 hours per week of direct therapy, which is a decrease of 15 hours per week in ABA therapy, is likely to lead to regression and return of the previous maladaptive behaviors. Accordingly, 30 hours per week of direct ABA therapy (0365T) and 14 hours per month of oversight (0369T) are medically necessary in this clinical setting.Final Result: The reviewer determined that a portion of 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis.  Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as being dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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 inpatient 30-day rehabilitation treatment program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Although chemical dependency specialty services were indicated, the medical records do not demonstrate the necessity of the residential level of care.  This patient was motivated to stop drinking, and he had safe housing.  He denied any cross-addiction with other substances.  The patient had no psychiatric comorbidity.  There was no evidence in the record that the patient had previously engaged chemical dependency treatment services during the episode of illness, such as substance use counseling, anti-craving medication, sober living environments, intensive outpatient programming or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  In sum, the record does not reflect that comprehensive, evidence-based services provided in a less restrictive setting would have been inadequate.  All told, inpatient 30-day rehabilitation treatment program services provided were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for Optune therapy from 6/20/16 forward.  Findings:  The physician reviewer found that central nervous system tumors are classified by the World Health Organization based on their proliferative potential, morphology, and molecular genetics and are conferred grades I-IV.  Anaplastic astrocytomas and glioblastoma multiforme are high grade tumors that are best treated with resection, radiation therapy, and chemotherapy.  Chemotherapy prolongs survival, but the gains are modest.  The standard of care is to resect the glioblastoma multiforme maximally followed by treatment with temozolomide.  This patient has exhausted these options.  The U.S. Food and Drug Administration (FDA) has approved Optune, formerly known as the NovoTTF-100A device, to deliver alternating electrical fields to treat recurrent glioblastoma multiforme.  Recently, the FDA expanded the indication for Optune to include newly diagnosed glioblastoma multiforme when used along with temozolomide and radiation therapy.  There is sufficient medical evidence to demonstrate the safety of this device and it is medically justified and reasonable. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Two physician reviewers found that as a basic observation, DBT is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. A study evaluated the impact of adding DBT to full field digital mammography (FFDM) in the detection and diagnosis of breast lesions. The study demonstrated that screening sensitivity of full field digital mammography was increased from 60% to 94%, and specificity increased from 20.7% to 74% when DBT was applied. In addition, DBT allowed unnecessary biopsy to be avoided in 37.3% of patients. In this case, there are multiple indications for tomosynthesis for this patient. Her breasts are described as heterogeneously dense and tomosynthesis has the ability to separate out the overlapping structures enabling the possibility of demonstrating an otherwise occult tumor. Furthermore, tomosynthesis will better define a mass, especially when it is palpable. Based on the support in the peer-reviewed literature, the DBT was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.