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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested custom orthotic shoe inserts for treatment of her high arches and arch strain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested custom orthotic shoe inserts. The medical literature concluded the prescription of custom foot orthotics has gold-level evidence for painful pes cavus. Moreover, the medical literature concluded that custom made foot orthoses are significantly more beneficial than sham orthoses for treating foot pain associated with pes cavus. Custom made foot orthotics are generally utilized to treat painful foot deformity and the medical literature supports this practice. As such, the requested custom orthotic shoe inserts are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 Harvoni for eight weeks for treatment of her hepatitis C virus genotype 1b.  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 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. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is medically necessary.  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 has requested Harvoni for eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  The current medical evidence supports the requested medication in this clinical setting.  The requested treatment regimen is expected to potentially prevent further damage of the liver and disease progression.  It is advantageous to initiate treatment for patients with early stage disease.  All told, the requested Harvoni for eight 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 has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her fibromyalgia and chronic pain.  The physician reviewer found that in the medical literature, Andersen noted that the current evidence indicates that immediate, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. The author cautioned that in addition to lacking clinical benefit, routine lumbar imaging is associated with radiation exposure. In addition, this patients records do not include any indications for the requested MRI. All told, the requested MRI of the lumbar spine without dye is not medically necessary for evaluation of this patients low back pain.  Final Result: The reviewer determined that the requested diagnostic procedure is 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 skilled nursing facility (SNF) services, or in the alternative, admission to a rehabilitation facility for intensive physical and occupational therapy for treatment of his medical condition status post ischemic stroke. The physician reviewer found that the records document that this patient had lacunar stroke resulting in weakness, incoordination, and imbalance. The current medical literature reports a relatively small portion of patients who suffered from an acute first-ever stroke received rehabilitation consultation and inpatient rehabilitation treatment. In addition, studies show that post stroke rehabilitation at home can be effective in improving mobility and self-care. This patients initial care resulted in significant functional improvements. At that time, he was appropriate for discharge to home with assistance, or to a board and care facility. He did not require the ongoing daily nursing care that could be only provided at a SNF. Consistent with these findings, subsequent SNF services, or in the alternative, admission to a rehabilitation facility for intensive physical and occupational therapy were not and are not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 esomeprazole magnesium (Nexium) for treatment of her gastroesophageal reflux disease. The physician reviewer found that proton pump inhibitors are a class of therapeutically equivalent medications.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  The duration of action and side effects characterize proton pump inhibitor variations.  No particular proton pump inhibitor is overall superior, such that as a class proton pump inhibitors are interchangeable.  In this patients case, the records do not support that her gastroesophageal reflux disease is advanced, nor has she demonstrated intolerance to a specific proton pump inhibitor.  The available records do not indicate that she maximized medical acid suppression treatment.  A therapeutic substitution in proton pump inhibitors would not be expected to place her health at undue risk.  There is a lack of support for the requested medication in this clinical setting.  All told, the requested esomeprazole magnesium (Nexium) is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medicine 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:   The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees behavioral health issues. The providers notes indicate that after the patient addressed specific issues, the patient experienced relief of his anxiety and depression. Once the patient was able to accept the consequences of his actions and expressed willingness to work on his problems, he did not require treatment at the RTC level of care; he was not suicidal or a threat to others. All told, the records do not support the medical necessity of RTC for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The 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 Harvoni for eight 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.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, 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.  Initiation of treatment when patients have early stage disease may help avoid untoward complications from hepatitis C, including liver failure and extrahepatic complications from hepatitis C.  The evidence supports an eight-week course of Harvoni for non-cirrhotic patients with hepatitis C, genotype 1 infection who are treatment-naive.  All told, the requested medication Harvoni for eight 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) scan of the chest for evaluation of her right lung nodule. The physician reviewer found that in the medical literature, Naidich and colleagues reported that solitary, pure ground-glass nodule (GGNs) larger than 5 mm require an initial follow-up CT examination in 3 months to determine persistence, followed by yearly surveillance CT examinations for a minimum of 3 years if persistent and unchanged. Godoy and Naidich found serial CT imaging has demonstrated stepwise progression of these nodules in a subset of patients, characterized by increase in size and density of GGNs and development of a solid component. All told, the requested CT scan of the chest for follow-up of this patients medical condition is supported as medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested custom foot orthotics for treatment of the enrollees bilateral foot pain.  The physician reviewer found that this patient was forced to stop running due to severe symptoms of plantar fascial pain in both feet. At this point, even normal walking is very painful for this patient. Stretching exercises have been used consistently for months to years, without long lasting improvement. The patient has a diagnosis of a cavus foot with chronic plantar fascial pain bilaterally. Treatment modalities tried thus far have included muscle stretching exercises, shoe modifications, NSAIDs, and topical analgesics, without substantial improvement. In the medical literature, Najafi and colleagues concluded that custom foot orthoses are shown to be an effective treatment option for foot pain in the high arched, cavus foot. Young and colleagues found that along with stretching and physical modalities, custom arch supports are useful and effective in the treatment of adolescent and teen patients. In conclusion, the literature supports that, in certain cases, custom made orthotics are the best and most effective form of long lasting treatment for the painful cavus foot. Consistent with these findings, the requested custom foot orthotics are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 podiatric 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Prolia (denosumab) injections for treatment of his bone health.  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Denosumab is a humanized monoclonal antibody that binds to the RANK ligand. There is strong medical evidence supporting its use specifically in prostate cancer. A randomized clinical trial showed that denosumab was more effective than zoledronic acid. The authors concluded that Denosumab was better than zoledronic acid for prevention of skeletal-related events, and potentially represents a novel treatment option in men with bone metastases from castration-resistant prostate cancer. As such, the denosumab injections were likely to be more beneficial for treatment of the patients medical condition than standard therapy.  Final Result: Two 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 medical oncology and is actively practicing.  Two reviewers are board certified in medical oncology 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 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation supports the medical necessity of the requested medication.  The patient has advanced disease.  The records do not document contraindications to treatment, and he is motivated to be treated.  Based on the information submitted for review, this patient appears to be a high priority individual for treatment with Harvoni.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  Final Result: Three 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 has requested Harvoni for eight weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Hepatitis C virus direct-acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.  The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C virus infection, namely those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of hepatitis C infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis.  This patient does not meet the criteria as high priority for treatment.  All told, the requested Harvoni for eight weeks is not medically indicated for the treatment of this patient. Final Result: Three 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. 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 requested a power seat elevator for her power wheelchair for treatment of the enrollee, who has a history of a spinal cord injury. Findings:  The physician reviewer found that with power seat elevation, the patient would be able to adjust the seat of her wheelchair to be level with the transfer surface, to perform a level surface transfer independently with a sliding board.  Therefore, the power seat elevation feature is needed in this patients case.  This recommendation is consistent with the current standard of care in the field of rehabilitation medicine.  Customized power mobility equipment to allow independence with transfers is an appropriate practice in rehabilitation.  Because power seat elevation significantly facilitates transfers and promotes independence in this patients case, the requested power seat elevator for her power wheelchair is medically indicated. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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.