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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for psychological testing for evaluation of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for psychological testing is not medically necessary for evaluation of the patients behavioral health conditions. The medical records submitted for review do not demonstrate a clinical indication for psychological testing. In general, ADHD and anxiety disorders are diagnosed with a complete history, physical examination to rule out other causes of problems and a mental status examination. Additional questionnaires, such as the Conners Parent Questionnaire and Teacher Questionnaires are also helpful. In this case, the Parent Questionnaire is consistent with the diagnosis of ADHD. However, there is no Conners Teacher Questionnaire provided for review. In addition, the patients fourth grade report card submitted for review does not show any major concerns. The report card shows that the patient has exceeded standards for listening actively, following directions, staying on task and using time efficiently, completing class work on time, completing homework on time and collaborating well with others. Based on the documentation submitted for review, there is a lack of support demonstrating the medical necessity for psychological testing to evaluation the patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency department services.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with undiagnosed HIV and chronic diarrhea that had been getting worse with five days of acute illness. At the ED he had a 103 degree fever, hyponatremia of 129, borderline low serum bicarbonate, and leukopenia. He was treated with intravenous fluids and started on oral antibiotics. In addition, he had undiagnosed but potentially very serious and life threatening underlying illness, HIV. He was at risk for serious outcome from his current illness and the signs and symptoms he was exhibiting would lead a prudent layperson in this circumstance to reasonably believe he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in emergency 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: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees autism spectrum disorder.  Findings: The physician reviewer found that in this clinical setting, a portion of the provider requested hours per week of ABA therapy, supervision and parent training is medically necessary for treatment of the patients autism. The patient has received high level ABA therapy since 2009. According to the documentation submitted for review, the patient has met some motor and language goals, but has not met many of the social goals. The patient continues to require a high level of ABA services due to his maladaptive behaviors that include aggression, non-compliance and whining. In addition, the progress reports show an increase in maladaptive behaviors. The Health Plans authorization of a reduced number of hours per week of ABA therapy is not clinically indicated for this patient. Decreasing ABA hours will likely lead to a return of previous behaviors and a loss of skills. Therefore, a portion of the requested hours per week of ABA therapy, supervision and training is medically necessary for treatment of the patients autism.Final Result: The reviewer 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: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the lumbar spine for evaluation of the enrollees back pain. Findings: The physician reviewer found that although this patient does not have a neurological deficit, the extent and nature of his T12 vertebral fracture cannot be gleaned from the x-ray report. The American College of Radiology (ACR) recommends advanced imaging with MRI when a compression fracture interferes with activities of daily living activities such as detailed for this patient. The rationale is to determine the extent of the fracture, assess the posterior elements for displacement, and determine the extent of canal encroachment. The best exam for this determination is the requested MRI of the lumbar spine. The patient does not exhibit point tenderness over the dorsal spine and the T12 vertebral body will be included in the field of view of the lumbar spine. Thus, the requested MRI of the lumbar spine is supported as medically necessary for further evaluation of this patients T12 vertebral compression fracture.Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of the enrollees systemic lupus erythematosus (SLE). Findings: The physician reviewer found that this patient presents with a history of SLE, achalasia, gastroparesis and neurogenic bladder. There are two randomized controlled trials evaluating the use of Rituxan in patients with moderate to severe SLE which failed to demonstrate significant benefit compared to placebo. Merrill and colleagues reported that no differences were noted between placebo and rituximab in the primary and secondary end points. Further evaluation of patient subsets, biomarkers, and exploratory outcome models may improve the design of future SLE clinical trials. Rovin and colleagues reported on the lupus nephritis assessment with Rituxan (LUNAR) study. The authors concluded that Rituxan did not improve clinical outcomes after one year of treatment. Currently, the literature does not support its use in this clinical setting. Accordingly, the requested Rituxan is not medically necessary for treatment of this patients diagnosis of SLE.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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the medication Vimpat 900 mg per day for treatment of the enrollees partial complex seizures.  Findings: The physician reviewer found that Vimpat is an anti-seizure medication that is commonly utilized to treat patients with epilepsy. However, according to the manufacturer, the maximum daily dose should not exceed 400 mg per day. Specifically, the manufacturer stated that adverse events have been observed after supratherapeutic doses were administered. These events included cardiac arrhythmias, status epilepticus, convulsions and increased seizure frequency and duration. The manufacturer further reported that in one case, after receiving Vimpat 900 mg/day for 23 days, the patient experienced increased seizure duration and frequency. The maximum recommended daily dose of Vimpat in patients with partial onset seizures is 400 mg and higher doses are not recommended per the manufacturer guidelines. In this case, a 900 mg per day dose as requested by the patient is not medically indicated. A dose of 900 mg per day may expose the patient to a very high risk of cardiac problems and higher risk of seizures. The requested medication dosage is unsafe and not recommended by the manufacturer and the current medical literature. For these reasons, the requested Vimpat for 900 mg per day for 30 days is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested medication dosage 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: An enrollee has requested authorization and coverage for full body magnetic resonance imaging (MRI) for evaluation of the enrollees systematic sclerosis. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for full body MRI. The medical records submitted for review do not demonstrate progression of symptoms or concern for new abnormality. The patient has had negative chest x-rays, negative CT scans of the chest and pelvis, and negative MRI of brain. Further, there is a lack of medical literature available that supports full body MRI in this clinical setting. All told, the requested full body MRI is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a lightweight folding power operated vehicle (POV)/scooter for treatment of the enrollees Kennedys disease. Findings:  The physician reviewer found that the request for a lightweight folding POV is medically necessary for treatment of the patients medical condition. The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Patients exhibited high use and satisfaction with their power wheelchairs. In this case, the patient presents with declining functional mobility with frequent falls. The requested device is appropriate for treatment the patients motor neuron disease with progressive weakness and loss of balance. All told, the request for a lightweight folding POV/scooter is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a power operated scooter for treatment of the enrollee, who has a history of midfoot and metatarsophalangeal osteoarthritis. Findings:  The physician reviewer found that the records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that the patient is independent with household ambulation, and her mobility deficits are being addressed with a cane or walker.  She does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her community level mobility.  Physical activity and exercise, moreover, are generally appropriate and recommended for conditions such as obesity and back pain, and for general musculoskeletal health.  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: Physician reviewer number one 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: An enrollee has requested authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should 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. Zepatier for 12 weeks is also a recommended regimen, without a requirement for NS5A resistance testing in genotype 1b, and the guidelines recommend either Harvoni or Zepatier as acceptable therapy. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Given the lack of documentation showing that Zepatier has been authorized for this patient, treatment with Harvoni for 12 weeks is 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: An enrollee has requested authorization and coverage for growth hormone (GH) therapy, Genotropin 1.4 mg/0.25 mL syringe for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that the patient has short stature and constitutional delay with an adult predicted height that is only 57 inches, which is 3 SDs below the mean. The patient meets standard U.S. Food and Drug Administration (FDA) criteria for treatment of idiopathic short stature. According to the Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 SDs below the mean for age or more than two SDs below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets most of these criteria. Thus, the requested GH therapy, Genotropin 1.4 mg/0.25 mL syringe is supported as medically necessary for treatment of this patients idiopathic short stature. 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 pediatrics and pediatric endocrinology 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

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: All three 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus with unknown genotype.  Findings: The physician reviewer 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 limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, Harvoni is a recommended regimen for certain hepatitis C genotypes, but not others. For example, the medication would not be appropriate for treatment of genotypes 2 or 3, while it may be appropriate for genotypes 1 or 4 (Kowdley, et al; Keating, et al). Cure of hepatitis C is indicated, as AASLD/IDSA guidelines cite data showing increased survival with earlier treatment (Jezequel, et al). However, although treatment of hepatitis C is needed, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary based on the information provided.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.