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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested tramadol for treatment of her medical condition. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the medication at issue. The American College of Rheumatology (ACR) list both non-pharmacologic and pharmacologic treatments for osteoarthritis pain of the hand, hip, and knee. The recommendations include both nonsteroidal anti-inflammatory drugs (NSAIDs), both oral and topical, and tramadol for the treatment of hand osteoarthritis. The recommendations specifically exclude opioid analgesics for the treatment of hand osteoarthritis. For osteoarthritis of the hip and knee ACR states, Pharmacologic modalities conditionally recommended for the initial management of patients with knee [osteoarthritis] OA included acetaminophen, oral and topical NSAIDs, tramadol, and intraarticular corticosteroid injections; intraarticular hyaluronate injections, duloxetine, and opioids were conditionally recommended in patients who had an inadequate response to initial therapy. In no instance were opioid analgesics recommended by ACR prior to tramadol. In addition, Koopman and Moreland note that tramadol does not have significant addictive tendencies and therefore have a lower potential for abuse than opioid analgesics.  In this case, the patient is doing clinically well on tramadol and there is no medical basis requiring that she switch treatment to an opioid analgesic. The Health Plans requirement to switch from a clinically effective non-opioid treatment such as tramadol to extended-release opioid analgesic is contrary to the patients best interest. In sum, tramadol was and is medically necessary for the treatment of this patients osteoarthritis.  Final Result:  The reviewer determined that the medication at issue was and 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient program level of behavioral health treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that this case encompasses all elements of the bio-psycho-social-cultural model of conceptualization and generates impairment in multiple domains.  The patient has attempted treatment of her illness burden in the outpatient setting.  Her treatment has consisted of pharmacotherapy and psychotherapy, but has netted no meaningful treatment gains.  Considering the illness burden and an undistracted therapeutic opportunity, intensive outpatient programming would be reasonably expected to significantly improve the patients condition.  All told, intensive outpatient program level of behavioral health treatment is medically indicated 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 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 cognitive behavioral therapy (CBT-I) for treatment of her insomnia. Findings:  The physician reviewer found that CBT-I is an accepted therapy for insomnia and is the standard of treatment according to the American Academy of Sleep Medicine. Compared to hypnotic therapy, CBT-I results in longer-sustained effects. Although many providers can be trained in treating insomnia, the provider should have specific training in CBT-I. In this case, the Health Plan does not contract with a CBT-I trained provider, and therefore, sessions with an out-of-network CBT-I-trained provider are medically reasonable and necessary.  Therefore, CBTI is clinically indicated for this patient. Final Result: The reviewersdetermined 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 sleep 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 Morphine for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking 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.  Long-term, short-acting opiates may also cause adverse outcomes.  Researchers also reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested Morphine is not medically indicated for the treatment of this patient. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be solved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. Considering the extra radiation dose, tomosynthesis has not been shown to provide significant increased value in patients who have normal breasts without dense tissue that could obscure an abnormality, especially when old mammograms are available for comparison, and there has been no interval change.  Final Result:  Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology 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 treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive, non-cirrhotic, genotype 1a patients should be treated with Harvoni for 12 weeks, or with Viekira Pak and ribavirin for 12 weeks.  Although treatment of hepatitis C is necessary, the information supplied in this case does not provide justification to support coverage of Harvoni over Viekira/ribavirin. No head-to-head clinical trials have compared these medications, and the patient does not have anemia, pregnancy, or other contraindications to ribavirin.  No clear contraindication to ribavirin is presented in this case.  For these reasons, the requested treatment with Harvoni for 12 weeks is not medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages in the interpretation of mammograms.  The main advantage is the ability to separate dense glandular elements from underlying architectural distortion/mass which in turn is associated with an increase in detection of small cancers and decrease in callbacks.  For these reasons, the inclusion of breast tomosynthesis was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  Final Result: Two reviewers determined that the services at issue were 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 reviewers are board certified in diagnostic radiology 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 an anesthesia procedure on the mouth for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients.  This patent has situational anxiety, requires extensive dental treatment and is uncooperative.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested anesthesia procedure on the mouth is medically indicated 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 anesthesiology with sub-specialty certification in pediatric anesthesiology 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 an inpatient hospital stay for treatment of her medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient hospital stay has not been established. According to Lippmann and Lukacz, same-day discharge from the hospital after laparoscopic hysterectomy is a safe option for women without perioperative complications or comorbidities that require inpatient observation and care. The patient was admitted for an elective laparoscopic hysterectomy with salpingo-oophorectomy. There were no acute signs or symptoms at the time of admission and no uncontrolled comorbid conditions. The procedure note documented that the patient tolerated the procedure well. There was minimal bleeding. The Post-Anesthesia Care Unit (PACU) course was uneventful and the patient was admitted to the hospital with orders for routine monitoring of vital signs, post-operative laboratory studies and Foley insertion for urinary retention. There was no documentation from the physician as to why the patient was admitted as an inpatient, as opposed to being discharged or remaining on observation status following recovery. The patient remained stable with minimal bleeding, and no fever. She could have been treated at a lower level of care. For the reasons provided, the services at issue were not medically necessary.  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 and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested balloon sinuplasty for treatment of her medical condition.  Findings: Three physician reviewers found that chronic rhinosinusitis is clinically defined as symptomatic involvement of the paranasal sinuses with complaints of facial pain, pressure, discolored anterior and posterior nasal drainage and discharge along with associated symptoms of low-grade fever usually lasting more than 12 weeks unrelieved with appropriate medical management with nasal irrigation techniques, antibiotics, adjunctive therapies including topical nasal steroids and objective documentation based on CT imaging showing mucous membrane changes within the paranasal sinuses. In this case, the patient does not meet clinical criteria as the records submitted showed that the CT scan was normal with no evidence of obstruction. Additionally, the patients symptoms are of recurrent acute infections which may be provoked possibly by allergy or viral syndrome. Clinical indications for sinus surgery have not been met in this clinical scenario. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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:   All three reviewers are board certified in otolaryngology 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 Provigil (modafinil) for treatment of her condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the medical necessity for the requested medication has not been established. There is a lack of a documentation describing the patients degree of fatigue, consequences of fatigue, contributing factors to the fatigue, previous therapeutic trials, and current status of the MS. Given the lack of information provided for review, modafinil is not medically necessary. 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 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 inpatient psychiatric hospital services for treatment enrollees behavioral health condition. Findings:  The physician reviewer found that upon review of the documentation provided, there was no evidence of acute psychosis subsequent to the patients initial treatment. After the period of initial crisis stabilization, the patient did not present as danger to self or others. All told, the patients symptoms were stable after initial inpatient hospitalization and she no longer presented as an imminent risk to self or others after this period of time. Based on the submitted documentation, the requested inpatient psychiatric hospital services were not and are not medically necessary for treatment of the 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 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 24 weeks for treatment of his 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines state that patients with cirrhosis are high priority for treatment, and patients with diabetes are at risk for fast progression of fibrosis.  Per the guidelines, ribavirin-ineligible patients with decompensated cirrhosis, regardless of prior treatment, should be treated with Harvoni monotherapy for 24 weeks.  There is data to support this regimen, and the guidelines also cite a study demonstrating that 12 weeks of Harvoni monotherapy is inadequate.  For these reasons, the requested treatment with Harvoni for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center (RTC) for treatment of enrollees behavioral health condition.  Findings:  The physician reviewer found that per the submitted documentation, the patient is both medically and psychiatrically at high risk at this time. Thus, the patient requires continued residential treatment center (RTC) services to avoid risk of serious harm or complications. All told, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewers 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 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.