Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested prolotherapy (platelet rich plasma injections) for treatment of her medial knee pain. Findings:  Three physician reviewers found that according to the available scientific literature, the use of platelet-rich autologous blood or plasma therapy has not proven to be an effective treatment for meniscal pathology, ligamentous knee injury, chondral knee injury/pathology, patellofemoral syndrome, knee arthropathy or any other knee condition. There are very limited published high-grade clinical studies to support the efficacy of autologous platelet-rich plasma injections for any of these or other musculoskeletal conditions with respect to any clinically or functionally relevant outcomes. Multiple reviews have concluded that there is a lack of high-grade evidence to support the efficacy of this intervention.  Given the lack of high quality medical literature establishing its effectiveness, prolotherapy (PRP injection) remains an unproven therapy at this time. There is also a lack of evidence that it favorably modifies the clinical course of any musculoskeletal condition greater than a placebo effect. The knee injury sustained by this patient is a condition that generally resolves with more conservative management and the passage of time. In sum, the services at issue were 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 services at issue were 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: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain management and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation with sub-specialty certification in sports medicine 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor.  Harvoni is U.S. Food and Drug Administration (FDA) indicated for the treatment of chronic hepatitis C (CHC) genotype 1 infection in adults. In addition, Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommendation for treatment of HCV patients with this patients characteristics (AASLD/IDSA guidelines).  Research shows that once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. For patients such as this patient with viral loads less than 6 million IU/mL, Harvoni for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. The patients records do not support advanced fibrosis; however, the medical appropriateness of HCV treatment, as per AASLD/IDSA recommendations, exists regardless of fibrosis score. Specifically, the AASLD/IDSA guidelines support treatment in all HCV infected persons, except those with limited life expectancy of less than 12 months. For these reasons, the requested Harvoni is medically necessary for treatment of the patients HCV.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a diagnostic test with a wireless capsule endoscopy for evaluation of her Celiac disease (CD). Findings:  Two physician reviewers found that according to the American College of Gastroenterology guidelines, a capsule endoscopy should not be used for an initial diagnosis except for patients with positive celiac sprue serology who are unwilling to undergo upper endoscopy and biopsy. The diagnosis is confirmed by duodenal mucosal biopsies. The sensitivity of capsule endoscopy is less when there is partial villous atrophy and all non-atrophic lesions (Marsh III) may elude visual detection. The capsule endoscopy should be reserved for the patients with complicated CD, such as patients with refractory CD and persistent diarrhea, abdominal pain, weight loss and hypoalbuminemia. In this case, the patient has been doing well on gluten-free diet, and has no pain and diarrhea, and no clinical evidence of refractory CD.  Given the above, the wireless capsule endoscopy is not supported by the clinical documentation provided for review.Final Result: Two 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: Reviewers 1, 2, and 3 are board certified 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for the treatment of her migraines.Findings:  Three physician reviewers found that Botox has been demonstrated to be beneficial for chronic migraine which can be defined as headaches greater than 14 days per month, at least eight of which are migraine or linked to migraine.  In this patients case, the records do not confirm this diagnosis.  The provided records do not document any information about the patient clinically, such as baseline headache frequency, number of prior Botox injections, or any evidence that there has been a benefit with Botox.  All told, Botox injections were not and are not likely to have been superior over other treatment options.  Final Result: Three reviewers determined that the services at issue were not, and 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 neurology, 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 colonoscopy diagnostic screening. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested colonoscopy. Based on national guidelines, the patient should undergo a surveillance colonoscopy five years after the last colonoscopy.  The patient had a single polyp, with low risk features, noted on his last colonoscopy occurring within these guidelines, The patient is currently asymptomatic without signs or symptoms of colorectal disease. Therefore, in this clinical setting the appropriate surveillance should be at five years after his last colonoscopy. Therefore, the requested colonoscopy is not medically indicated for this patient at this time.  Final Result: One reviewer determined that the requested services are 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 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 inpatient psychiatric hospitalization for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the medical records submitted for review support the medical necessity of inpatient psychiatric hospitalization. In this case, the patient is plagued with co-occurring substance dependence and a serious formal thought disorder, which as a class represents the most severe of psychiatric illnesses. Discharging any patient prematurely under such circumstances would be inconsistent with good medical practice, thus a conservative hospitalization was to be expected. Considering the longitudinal history of the case, the patient had not yet consolidated the treatment gains necessary to succeed outside the hospital and treatment in a less restrictive setting at the time would have been inadequate. There was no reasonable discharge plan at the time. In sum, considering the case in its entirety within the context of current practice guidelines and relevant peer-reviewed literature, the inpatient services in dispute were for active treatment and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Additionally, the admission was successful in that the patient was directly transferred to a long-term unit without interruption of care.  All told, the services at issue were safe, appropriate and medically necessary.   Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 pelvic floor physical therapy for treatment of her medical condition.  Findings:  The physician reviewer found that chronic pelvic pain syndromes are not uncommon and can cause impaired quality of life.  These pain syndromes, including pudendal neuralgia, are poorly understood, and there is limited high-grade evidence available to guide treatment.  In this patients case, there are no objective indications that the formal physical therapy services that she has been receiving have been effective or necessary.  Despite the therapy interventions that were being provided, she had persistent symptoms that fluctuated and generally worsened.  She continued to have pain and functional limitations.  She required ongoing injection therapy and increases in her pain medications.  There were no exercises or modalities performed in the formal therapy setting that could not have been performed independently or substituted with independent exercises or modalities with a reasonable expectation of differences in clinical course or outcomes.  The patient should have already been transitioned to an independent program.  Formal manual therapy on a chronic basis in the setting of chronic neuromusculoskeletal pain conditions is not proven to be effective in the medical literature.  All told, the requested pelvic floor therapy is 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested additional hours per week (for a total of 30 hours) of applied behavioral analysis (ABA) services for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that in this clinical setting, an increase of ABA services to 26.5 hours per week is medically necessary. The research study done by Orinstein and colleagues found that children with optimal outcome after an autism diagnosis were more like to receive ABA and more likely to start it at an earlier age. However, the children with optimal outcome had a mean of 25 hours or services in age 4 and 18 hours at age 3. According to the documentation submitted for review, the patient is having worsening of maladaptive behaviors, thus his current ABA frequency is not sufficient. However, the patient shows cognitive, communication and adaptive progress with the current level of hours.  Final Result: Two reviewers determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is 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 lorazepam for treatment of her behavioral health condition. Findings:  The physician reviewer found that the medical records submitted for review does not support the medical necessity for the requested medication. There is a lack of longitudinal history detailing the illness burden or interventions tried and failed. It is unclear if lorazepam, which is potentially unique from the formulary equivalents as it bypasses phase I hepatic metabolism and has a relatively delayed onset of action with no active metabolites, had been prescribed previously. Moreover, based on the documentation submitted for review, it is not possible to assert with any degree of certainty that lorazepam would be significantly more effective and/or better tolerated than the two formulary alternatives, diazepam and alprazolam. Thus, based on the documentation provided, the requested medication 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested left radical nephrectomy and related services on an emergent or urgent basis. Findings:  The physician reviewer found that the submitted documentation does not demonstrate the patient was experiencing an emergency medical condition. In this case, the patient presented for a left radical nephrectomy due to a renal mass found on imaging. Emergency surgery was not recommended at the time the mass was found or on follow-up shortly thereafter. The patient was given various treatment options and decided to undergo left radical nephrectomy. At that time, the patient was not experiencing acute symptomatology that was likely to place his health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part without surgical intervention. All told, based on the documentation provided for review the patients symptoms did not meet prudent layperson criteria for emergency services on the dates in question.  Further, it has not been established that criteria for urgently needed services were met. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. Moreover, the patient was given the option of returning home for treatment by his provider. In this case, treatment could have been delayed until he returned home where he could have been safely treated. There was no indication that a prudent layperson in a similar situation would have believed immediate medical attention was necessary to prevent serious deterioration of ones health. Further, there was no evidence that his condition was deteriorating or that he was in acute distress. In sum, based on the patients clinical presentation he did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in urology 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 treatment of his 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 report that patients with cirrhosis are highest priority for therapy. Per guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD guidelines cite data showing decreased survival with delayed treatment. The guidelines also recommend the use of Viekira Pak and ribavirin in certain genotype 1a patients, but do not recommend this combination in treatment-experienced patients with cirrhosis due to risk for severe decompensation of liver disease.  For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  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:  The 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:   An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Evidence-based medical guidelines and peer-reviewed criteria have been met. This patient presents with persistent and worsening low back pain with radiculopathy. Significant functional difficulty is documented. Clinical examination findings are consistent with imaging evidence.  Detailed evidence of a recent, reasonable and/or comprehensive non-operative treatment protocol trial and failure has been submitted.  There is discussion and imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion 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 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.