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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Harvoni 90/400 mg tablets for 12 weeks for treatment of the enrollees hepatitis C infection. 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 recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication regimen is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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: The parent of an enrollee has requested authorization and coverage for group speech therapy with the enrollees peers, that excludes children nine years and younger. Findings:  The physician reviewer found that the request for group speech therapy, that excludes children nine years and younger is medically necessary for this patient. There is medical literature demonstrating that social skills groups can improve social competence for some children and adolescents with autism. In this case, the patient has mastered social interactions with younger peers. As such, group speech therapy that excludes children younger than nine years is clinically indicated to have the patient develop social goals of interacting appropriately with same age peers. Therefore, the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira Pen Crohn-UC-HS starter 40 mg/0.8 mL pen IJ kit. Findings:  The physician reviewer found that the current medical literature supports the medical necessity of Humira in this clinical setting. Failure of tumor necrosis factor (TNF) inhibitors can occur for many reasons. This patient has failed Remicade given colonoscopy findings showing ongoing inflammation while on Remicade. In the ULTRA 1 trial, which was a high-quality randomized double-blind placebo-controlled trial, Humira proved safe and effective for induction and maintenance of remission of ulcerative colitis; it subsequently proved to increase maintenance of remission, mucosal healing, and quality of life over multi-year follow-up. A TNF inhibitor such as Humira is appropriate therapy over immunomodulators, which can take several months to induce remission.  The patient reports that he has already failed 6-mercaptopurine.  Additionally, American Gastroenterological Association guidelines for management of ulcerative colitis state that after failure of a TNF inhibitor such as Remicade, another TNF inhibitor (such as Humira) or the medication vedolizumab should be used; immunomodulators such as azathioprine and 6-mercaptopurine are useful as adjunct medications only.  For these reasons, the requested Humira Pen Crohn-UC-HS starter 40 mg/0.8 mL pen IJ kit is medically necessary for the treatment of this patient. Final Result: The 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: 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of child enrollee has requested rizatriptan 5 mg, 30 tablets per month for treatment of the her migraines. Findings:  The physician reviewer found that he submitted documentation supports the requested medication quantity in this clinical setting.  There is no one size fits all for treatment guidelines in the pediatric and adolescent population for migraine and its variants that include cyclic vomiting.  This patients symptoms are affecting her quality of life.  Rizatriptan has been found to be safe and well-tolerated in this age group when taken orally.  Migraine frequency and its disabling associated symptoms can frequently flare, and 30 tablets of rizatriptan per month may be warranted when patients experience an increase in the frequency of migraine headaches. Final Result: The reviewer determined that the requested medication quantity 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 special qualification in child neurology 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 Klonopin for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this case, the patient meets criteria for sedative, hypnotic or anxiolytic (benzodiazepine) use disorder. More than one provider involved in the patients care have agreed that Klonopin is no longer indicated. The patients urine drug screen was negative for benzodiazepine. Klonopin has a half-life of 15 to 30 hours. Thus, at steady dosing of 2 mg three times a day, the urine drug screen would be expected to detect benzodiazepine more than five days after the last dose. Further, the patient had negative benzodiazepine screens on several dates interspersed among positive results during the time frame. 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 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 Hysingla ER 80 mg for treatment of the enrollees chronic pain syndrome. Findings: The physician reviewer found that Hysingla is an opioid analgesic recommended after a trial of a first-line oral analgesic has failed. Opioids are generally not recommended as first-line therapy but, when used, providers should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. In this case, the records do not document that the use of the prescribed opioid medication decreased the patients level of pain from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription. 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 authorization and coverage for Harvoni 90-400 mg for a duration of 24 weeks for treatment of the enrollees hepatitis C. 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.  In this patients case, the provided APRI score is not consistent with advanced fibrosis or cirrhosis.  Per the records, the patient does not have cirrhosis, and no other reason for urgent re-treatment compatible with the high-urgency group in the guidelines is provided.  The guidelines do not support treatment at this time. Final Result: The reviewer determined that the requested medication 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 reimbursement for the Optune device and transducer array supplies for six month rental/six total units for treatment of the enrollees glioblastoma multiforme. Findings: The physician reviewer found that in the medical literature, treatment with Optune tumor-treating fields (TTFields) in combination with maintenance Temodar prolonged progression free survival and overall survival in patients with glioblastoma after chemoradiation. The study concluded that of 315 patients with glioblastoma who had completed standard chemoradiation therapy, adding TTFields to maintenance temozolomide chemotherapy significantly prolonged progression-free and overall survival. Per the National Comprehensive Cancer Network (NCCN) guidelines, Optune with Temodar following treatment with radiation and Temodar is recommended for patients with methylated and unmethylated glioblastoma. Final Result: The reviewer determined that the equipment at issue was 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Lyrica for treatment of the enrollee, who has a history of fibromyalgia. Findings: The physician reviewer found that the American College of Rheumatology recommended preliminary diagnostic criteria for fibromyalgia. These criteria are recommended when assessing the physical and psychological symptoms of patients with fibromyalgia. Specifically, in this patients case, the documentation provided does not indicate that she has a widespread pain index score of at least 7 and a symptom severity score of at least 5. Chronic pain that has no hope for a cure can be considered palliative in nature and treatment. The stepwise World Health Organization ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Behavior therapy has not been discussed or noted to be completed despite much research to support its use. In addition, the records do not show that all non-opioid medications classes have been optimized or tried. Finally, multiple minimal requirements for controlled substance prescribing have not been performed and the need to use them as the primary medication treatment strategy for pain have not been established in this patients case. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that this patient was struggling with interpersonal issues along with mood and anxiety issues. The medical records do not support active suicidal ideation or psychosis at the time the patient was admitted to the residential treatment center or during the disputed period. The records indicate the patient was open to receiving therapy to aid with his behavioral health issues. He had minimal prior behavioral health treatment. The records do not indicate that he had any intensive outpatient services of any type.  There were no significant or severe behavioral problems noted. Based on the records, the patient did not need the restrictiveness of a residential psychiatric treatment facility in order to receive his care. The records indicate the treatment objectives could have safely and effectively been addressed in a less restrictive setting. Residential treatment is used for acute stabilization of psychiatric conditions and is not evidenced-based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care. There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. 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 with sub-specialty certification in child and adolescent 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 for Otezla 30 mg for treatment of the enrollees psoriasis vulgaris. Findings: The physician reviewer found that the records provided for review document that this patient has tried and failed a three month course of methotrexate and a three month course of Humira as well as topical and intralesional steroids and topical retinoid creams. The patient has plaque psoriasis affecting the scalp, which may not provide a high body surface area of involvement, but precludes treatment with phototherapy due to inadequate penetration to the scalp. Enbrel and Humira have the same mechanism of action. Thus, when either Humira or Enbrel has been ineffective, the other medication is not likely to be an effective treatment alternative. 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 dermatology 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 pelvis magnetic resonance imaging (MRI) performed for evaluation of the enrollees elevated prostate specific antigen (PSA). Findings:  The physician reviewer found that there is limited data regarding the patients prostate examination, and there is no record of a digital rectal examination. In addition, there is no record of ultrasound guided prostate biopsy or imaging prior the MRI performed. No follow-up PSA level was obtained. Given the current guidelines from the National Imaging Associates (NIA), the use of MRI as a screening tool for prostate cancer in this clinical setting was not indicated. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 authorization and coverage for lumbar spinal fusion (CPT codes: 63047, 63048, 22630, 22632, 77002, 22612, 22614, 22842 and 20936) and one day inpatient stay following the lumbar spine surgery. Findings:  The physician reviewer found that per the North American Spine Society (NASS), lumbar fusion is indicated for patients with specific diagnoses with qualifying criteria when appropriate. In this case, there is lack of evidence on MRI demonstrating severe spinal stenosis or radiographs demonstrating segmental instability to warrant the requested revision lumbar fusion. As there is a lack of medical documentation demonstrating a pattern of radiculopathy/neurogenic claudication explained by the imaging findings, stenosis resulting in functionally limiting motor weakness, and 6-12 weeks of non-operative treatment has been performed, the requested lumbar spinal fusion (CPT codes: 63047, 63048, 22630, 22632, 77002, 22612, 22614, 22842 and 20936) and one day inpatient stay following the lumbar spine surgery is not supported as medically necessary for treatment of this patients low back pain. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for transcranial magnetic stimulation (TMS) treatments provided for treatment of the enrollees major depressive disorder. Findings: Two out of three physician reviewers found that according to the Clinical TMS Society While peer-reviewed studies demonstrate that the majority of patients who receive acute benefit from TMS therapy do so within 4-6 weeks, it is reasonable to continue treatment beyond 6 weeks in specific circumstances. In this case, although the patient had improved, a plateau had not been obtained. The note stated that the patient was experiencing improvement, was working every day, and that her energy was returning. The provider noted the patient was definitely better. Given the significant improvement in the patients symptoms noted in the record, the TMS treatments were clinically indicated within weeks. As such, the TMS treatments provided were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, but not thereafter. Final Result: The reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are 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.