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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a clinical chemistry test for treatment of the enrollees Crohns disease.  Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available options. The Prometheus Anser IFX Test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. There are few well controlled clinical trials to confirm that use of the Anser IFX test leads to improved patient outcomes or quality of life as opposed to the standard method of treatment. The clinical utility of measuring drug antibody concentrations is on a case-by-case basis, and based on the clinical documentation submitted for review, it has not been established how the patients management would change based on test results. In addition, there are technical factors relating to the use of different assay methods across studies. It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established, such as is this case. In sum, the measurement of antibodies to infliximab in patients receiving treatment with infliximab has not been established. Thus, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewers 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to the conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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: An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C virus (HCV). Findings:  Two physician reviewers found that as 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 U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. The goal of treatment of HCV-infected persons is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by sustained virologic response. Therefore, Harvoni for 12 weeks is medically necessary to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. 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. The 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 Linzess for treatment of his slow transit constipation. The physician reviewer found that according to the documentation submitted for review, this patient presents with chronic idiopathic constipation, with reports of infrequent bowel movements, difficulty during defecation, abdominal pain, cramps and nausea. The patient reports his constipation has persisted despite opioid withdrawal. Linzess is a guanylate cyclase-C agonist that is U.S. Food and Drug Administration (FDA) indicated in adults for treatment of chronic idiopathic constipation. In this case, the patient has benefitted from use of Linzess. Thus, it is medically appropriate for him to continue with Linzess. Based on the medical literature and clinical documentation provided, Linzess is medically necessary for treatment of the patients medical condition. 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 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 transcranial magnetic stimulation for treatment of her major depressive disorder.  Findings:  Two physician reviewers found that the American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There is sufficient evidence in the peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this patients case.  The record reflects that the patient is enduring significant affective impairment consistent with the acute phase of a depressive episode.  She has pursued evidence-based non-pharmacologic interventions and has failed at least one antidepressant trial.  Considering the case in its entirety within the context of the most current practice guidelines, transcranial magnetic stimulation is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Therefore, the requested transcranial magnetic simulation is likely to be of greater benefit than other treatment options. Final Result:  Two reviewers determined that the requested services are 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: All three reviewers are board certified in psychiatry 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 occupational therapy and sensory integration occupational therapy for treatment of the enrollees autism spectrum disorder.   The physician reviewer found that in this case, traditional OT is not medically necessary as the patients fine motor skills are in the average range. However, sensory integration OT is medically necessary for treatment of the patients medical condition. According to the American Academy of Pediatrics Traditional occupational therapy often is provided to promote development of self-care skills (eg, dressing, manipulating fasteners, using utensils, personal hygiene) and academic skills (eg, cutting with scissors, writing). Occupational therapists also may assist in promoting development of play skills, modifying classroom materials and routines to improve attention and organization, and providing prevocational training. Sensory integration (SI) therapy often is used alone or as part of a broader program of occupational therapy for children with ASDs. The goal of SI therapy is to address deficits in neurologic processing and integration of sensory information to improve the individuals ability to interact with the environment. According to a paper by Roley  and colleagues, Sensory activities may be helpful as part of an overall program that uses desired sensory experiences to calm the child, reinforce a desired behavior, or help with transitions between activities. According to the documentation submitted for review, OT sensory integration therapy has been effective for this patient with a reported worsening of maladaptive behaviors when OT sensory integration therapy is reduced. In this case, sensory integration OT is medically necessary for treatment of the patients maladaptive behaviors including wandering, self-injury and aggression to others. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

An enrollee has requested a 12 week course of Harvoni for treatment of her chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as 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 U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  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. The 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 weekly or biweekly therapy appointments for treatment of his behavioral health condition.  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. Effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with major depressive disorder.  Current practice is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which multiple sessions per week may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery. In this particular case, the patient was enduring an acute episode of illness. Although community programming is an important complementary intervention in any case, Al-Anon and monthly therapy appointments would be both inadequate for therapeutic consolidation.  The meta-analysis by Cuijpers and colleagues identified that at least 18 treatment sessions are needed to realize optimal effects of psychotherapy. In addition, the American Psychiatric Association Clinical practice guideline for the treatment of patients with major depressive disorder state the following, Regardless of the type of depression-focused psychotherapy that is selected, the clinician should carefully and systematically monitor the patients response to treatment, which can be facilitated by the use of clinician and patient rated scales at regular intervals. If 48 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. Thus, a course weekly individual therapy appointments with systematic monitoring would be safe, appropriate and reasonably expected to improve the patients condition and prevent a more serious episode of illness. Thus, the requested services are medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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 a power wheelchair group 4 (HCPCS code K0084 power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) for treatment of his cervicalgia, lumbar stenosis with radiculopathy, and disc herniation.  The physician reviewer found that in the criteria for a power wheelchair, the Centers for Medicare and Medicaid Services (CMS) criteria include inability to operate a manual wheelchair, bed or chair bound, and the patient must be able to safely operate controls. The patient is not bed or chair bound and has sufficient upper extremity strength to operate a manual wheelchair. In the medical literature, Shnayderman and Katz-Leurer also indicated that walking and aerobic exercise benefits patients with chronic low back pain. The patient has chronic pain and anatomic findings do not reveal spinal cord compression or nerve root compression which would lead to significant lower extremity weakness. Thus, the requested power wheelchair group 4 (HCPCS code K0084 power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an electrical bone growth stimulator for treatment of his scaphoid nonunion.  Two physician reviewers found that in this patients case, the requested device is not likely to be more effective than other treatment options.  The patient has a history of wrist trauma while playing football, with current x-rays demonstrating scaphoid nonunion.  The current medical evidence does not support the requested device in this clinical setting.  There is a paucity of randomized, placebo-controlled studies supporting the use of electrical bone growth stimulation in nonunion of the scaphoid.  The patient underwent scaphoid nonunion repair with iliac crest bone graft.  The records noted observed bleeding from both sides of the nonunion site, and this increases the likely success of non-vascularized bone graft.  Therefore, the requested electrical bone growth stimulator is not likely to be superior over other options.  Final Result: Two reviewers determined that the requested device is 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 orthopedic surgery 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 substance abuse residential treatment center services for treatment of his behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue.  The patient did not have severe withdrawal symptoms. He was not suicidal, homicidal, or psychotic. His hypertension was stable, and although he rated his depression and anxiety at high levels he did not require 24-hour supervision. He was willing to enter treatment and aware of the need to develop coping mechanisms. He had multiple episodes of substance abuse treatment with multiple relapses, making his risk for relapse high. He resided in sober living so his environment was safe. His alcohol use had adversely affected emotional, social, and vocational aspects of his life. Given all of these factors and carefully considering American Society of Addiction Medicine (ASAM) placement criteria, residential level of care was not medically necessary in this clinical setting. The patient could have been safely and effectively managed at a lower level of care, such as IOP (intensive outpatient) level of care. Thus, the services at issue were not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in addiction 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 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Harvoni has been approved by the U.S. Food and Drug Administration for the treatment of patients with HIV and hepatitis C, genotype 1.  Per the medical literature, the treatment of patients with HIV and chronic hepatitis C coinfection should be initiated at an early stage, regardless of fibrosis, to prevent progression of fibrosis to cirrhosis.  All told, the requested Harvoni for 12 weeks 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. 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.