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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested one hour per week of social skills group training for treatment of the enrollees autism spectrum disorder. The physician reviewer found that the medical literature demonstrates that both ABA and social skills groups are effective for patients with autism spectrum disorder. In this case, the patient receives 15 hours per week of ABA through school and community services. Adding social skills group to this level of intervention is reasonable and appropriate. According to the documentation submitted for review, the patients pragmatic language is the area with the most problems. Practicing pragmatic language one-on-one is less effective than in a group setting. Based on the clinical documentation provided, the patient will benefit from the addition of a social skills group. As such, the request for one hour per week of social skills group training is medically necessary for treatment of the patients autism spectrum disorder.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested facial feminization surgery for treatment of her gender dysphoria. The physician reviewer found that per the World Professional Association for Transgender Health (WPATH) Standards of Care, there is a divergence of opinions regarding whether facial feminization surgery is considered reconstructive. In the absence of definitive guidance on the classification of facial feminization procedures as reconstructive, determinations of medical necessity for such procedures must be made on a case specific basis. In this patients case, review of the submitted clinical documentation including photographic images demonstrates that the patients features are not overtly masculine. The patients nose, jaw/chin, brow, lips and trachea are within the anatomical range of normal of a natal female. The requested procedures are not medically necessary to modify masculine features. The proposed procedures are for the purposes of creating a more aesthetically desirable female appearance and are not medically necessary for treatment of the patients gender dysphoria. Furthermore, the proposed procedures do not meet reconstructive surgery criteria. The patients current facial features do not represent an abnormal structure of the body, as they fall within the anatomical standards for an individual of the female gender. As such, the requested services are not considered reconstructive in nature.  Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in plastic 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Zyprexa for treatment of his behavioral health condition.  The physician reviewer found that Zyprexa is not medically necessary for treatment of the patients medical condition. Zyprexa is a second generation, or atypical, antipsychotic medication that is approved by the U.S. Food and Drug Administration (FDA). One of its several indications is the treatment of schizophrenia. However, one factor that distinguishes the second generation class from the typical neuroleptics is the risk of metabolic syndrome, which is characterized by obesity, impaired glucose metabolism and dyslipidemia. Confounding this potential safety complication is that diabetes is up to four times more frequent in patients with schizophrenia compared to the general population. This relationship led to a collaborative effort between the American Psychiatric Association, the American Diabetes Association, the North American Association for the study of Obesity and American Association of Clinical Endocrinologists, the outcome of which was the development of consensus guidelines on monitoring and description of the differential risk of metabolic effects for the atypical antipsychotics. Zyprexa was described as having the greatest effect on weight and risk for diabetes. This association was illustrated again in the National Institute of Mental Health sponsored Clinical Antipsychotic Trials of Intervention Effectiveness study which noted that patients receiving Zyprexa demonstrated a greater than 7% weight gain from baseline in 30% of patients. With the experience of clinical practice and the guidance from national professional organizations, metabolic monitoring is now standard clinical practice during antipsychotic pharmacotherapy. As such, the requested medication cannot be considered safe for maintenance therapy, and thus is not medically necessary. Based on the documentation provided, Zyprexa is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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:  The parent of an enrollee has requested  residential treatment center (RTC) level of care services for treatment of the enrollees major depressive disorder and anorexia nervosa.  The physician reviewer found that based on the documentation provided, specialty services at the residential level of care were and are indicated for this patient struggling with the developmental stage of identity formation who has yet to consolidate the treatment gains necessary to succeed in a less restrictive setting. Further, considering her previous suicidality, recent acute psychiatric hospitalization and medical comorbidity, a conservative treatment course is to be expected. The patient has been engaged in active treatment based on an individual treatment plan that includes psychiatric and nutritional services, pharmacotherapy, and family counseling as well as individual and group therapies. Despite these interventions, the patient continues to subscribe to eating disordered schemas and distorted beliefs. Indeed, during her psychiatric appointment, the patient indicated she was not finishing her meals for fear of becoming fat. In the week prior, she had reported suicidal ideation and had her antidepressant increased. She remained nervous during family sessions and was described as depressed during process group. In such a state, the patient remains at elevated risk for undue morbidity and admission to a higher level of care in the absence of residential programming. In sum, the services in dispute were and are reasonably expected to improve the patients condition and prevent a more serious illness. Accordingly, the RTC services were and are medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a magnetic resonance imaging (MRI) of the left hip, and/or left upper leg, and/or left lower leg, and/or left foot for evaluation of her left leg pain.  The physician review found that according to the providers note, the patients symptoms may be related to L4 radiculitis. In addition, the recent MRI scan of the lumbar spine revealed findings which are compatible with nerve compression at the L4 and L5 levels. Thus, the additional imaging requested by the patient is not indicated until she has been evaluated by a spine specialist who can correlate the abnormal spinal MRI findings with the patients clinical symptoms. Also, due to the negative physical exam of the left leg including a negative Homans sign there are no clinical signs to indicate further testing for deep venous thrombosis. If there are any clinical findings which become suspicious for deep venous thrombosis, then a venous ultrasound would be indicated at that time. However, based on the available information, the requested MRI of the left hip, left upper leg, left lower leg, and/or left foot are not supported as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The 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 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 Subsys for treatment of the enrollees rheumatoid arthritis, psoriatic arthritis, severe degenerative arthrosis, bilateral knee pain, and degenerative lumbar disc disease.  The physician reviewer found that according to the U.S. Food and Drug Administration, Subsys is currently approved for treatment of breakthrough cancer pain in adult patients who are receiving and who are tolerant to opioids during the management of underlying persistent cancer pain. Additionally, Rauck and colleagues found that fentanyl sublingual spray results in effective treatment of breakthrough cancer pain, with a rapid onset of action that is well tolerated. Similarly, the National Comprehensive Cancer Network (NCCN) guidelines state that the use of sublingual formulations of fentanyl is considered an effective option for managing episodic breakthrough cancer pain. However, there is a lack of published medical literature supporting the use of Subsys for the treatment of breakthrough pain in cases not associated with cancer. This patients most recent clinical note indicated that the current medication regimen which did not include Subsys was effective. Without clinical trials demonstrating the long-term safety and efficacy of Subsys for breakthrough pain not related to cancer, the requested Subsys is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers 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), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to be treated with Harvoni for 12 weeks. These 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. Consistent with these findings, the requested Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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: All 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 treatment of her hepatitis C virus (HCV).  Two physician reviewers found that the requested medication is not medically necessary for treatment of the patients HCV. In this case, the patient presents with moderate to advanced fibrosis based on non-invasive testing. An average of these studies would suggest the patient has F3 fibrosis. As such treatment is medically indicated for this patient. However, the documentation submitted for review does not demonstrate the patient has a contraindication to Viekira Pak or ribavirin. The patient is being treated with Pravastatin, this medication can be stopped or the dose reduced while the patient is on Viekira Pak. In addition, the patient is also treated with epidural corticosteroid injections with triamcinolone, and it is safe to continue these injections while on Viekira Pak. As such, the request for Harvoni is not medically necessary for treatment of this patients medical condition. Final Result: Two reviewers determined that 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: All 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 Harvoni for treatment of her hepatitis C virus (HCV). Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated (Class I, Level A recommendation). For patients with genotype 4 HCV, the guidelines recommend treatment with daily Harvoni for 12 weeks (Class IIb, Level B evidence). These guidelines are based on multiple clinical trials. The SYNERGY trial demonstrated 100% sustained virologic response after 12 weeks of Harvoni (even though 40% of patients were prior treatment failures) in per-protocol analysis. There is support in the medical literature of the use of Harvoni for genotype 4 HCV patients. Given the above clinical guidelines and study data, Harvoni is medically necessary in this patients case.   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:  One reviewer is board certified in gastroenterology and is actively practicing.  Two 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested a high intensity focused ultrasound (HIFU) procedure for treatment of his prostate cancer. Three physician reviewers found that the services at issue were not likely to be more effective for this patient than other available treatment options. HIFU is a non-surgical, minimally invasive treatment option using ablative technology developed in the 1990s and is now becoming an alternative to radiation therapy. The role of HIFU as primary therapy for patients with prostate cancer is still controversial. In this case, the patient has localized prostate cancer which can be treated with several well-established and proven treatments including surgery, intensity-modulated radiotherapy (IMRT), and brachytherapy. HIFU has been used to treat prostate cancer and there are few published clinical data available. However, these data include small studies published from single institutions. There is a lack of randomized trials or large cohort trials supporting safety and efficacy of HIFU. Based on the records provided and medical literature cited, the HIFU procedure was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result:  Three reviewers determined that 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 urology and is actively practicing.  Two reviewers are board certified in radiation 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 Harvoni for treatment of his hepatitis C virus. Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For the reasons provided, Harvoni is medically necessary for treatment of this patients medical condition.  Final Result:  Three reviewers determined that that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewer 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus. Three physician reviewers found that according to 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 U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. In this case, the Health Plan has approved Viekira Pak which has been FDA approved for the treatment of patients with chronic active hepatitis C genotype 1 based upon clinical trials. Treatment with Viekira Pak is as safe and effective as Harvoni for genotype 1 patients. In this case, the documentation provided for review does not demonstrate the patient has contraindications to the use of Viekira Pak. As such the request for Harvoni is not medically necessary in this clinical setting. 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two 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.