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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance spectroscopy for evaluation of his medical condition.  Three physician reviewers found that in this patients case, the superior efficacy of the services at issue has not been established.  The records indicate that the patient has a history of adenocarcinoma of the prostate.  He was evaluated with magnetic resonance spectroscopy.  There is a lack of support for the services at issue in this clinical setting.  The utility and accuracy of prostate magnetic resonance spectroscopy for the diagnosis and monitoring of prostate cancer has not been demonstrated.  Therefore, magnetic resonance spectroscopy was not likely to be of greater benefit than other method of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in diagnostic radiology and is actively practicing.  Two reviewers are board certified in urology 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 a power wheelchair for treatment of his backache.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Auger and colleagues performed a literature review of power wheelchair usage and assigned most of the research designs as very low quality. A poor foundation of evidence challenges the provider tasked with determining the medical necessity of a power wheelchair for a specific patient. Power mobility can benefit specific patients, however in the present case there is a lack of evidence supporting the medical necessity for power mobility. The patient does not have any obvious medical indication for a power wheelchair. He can ambulate within his abode and he can ambulate with or without assistive devices. Additionally his abode is not wheelchair accessible. Based on the clinical documentation submitted, a power wheelchair is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the submitted documentation supports the requested medication in this patients case.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Harvoni has been approved by the U.S. Food and Drug Administration for all patients with chronic hepatitis C, genotype 1, regardless of fibrosis stage.  It is advantageous to treat patients before they progress to cirrhosis.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  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 Harvoni for treatment of his hepatitis C virus (HCV).  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment 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. AASLD/IDSA guidelines state that 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. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, this patient should be approved for Harvoni 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:  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 acupuncture for treatment of her neck, shoulder and back pain.  The physician review found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. According to the documentation submitted for review, the patient previously underwent acupuncture sessions which were documented as beneficial. Gains were described as symptom reduction, medication intake reduction and range of motion improvement. According to the patient, the benefits obtained from acupuncture were superior to benefits obtained with physical therapy, nerve blocks and epidurals. In regards to the patients neck complains, based on peer reviewed literature acupuncture is superior to conventional massage, dry needling of local myofascial trigger points, and sham laser acupuncture, for improving active range of motion, pain, shortening disease duration time and improving functional ability in patients with chronic neck pain, especially in patients with myofascial pain syndrome. In regards to lower back complains, acupuncture is recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Regarding the patients shoulder condition, the peer-review literature  supports acupuncture as appropiate as it offered good clinical results in diminishing symptoms, shortening disease duration time and improving functional ability, even in long-lasting disease (up to 10 years). Also acupuncture has been found to be an effective long-term treatment for patients with shoulder pain (from soft tissues lesions). Given the patients continued symptomatology which already benefitted with prior acupuncture care and based on peer-review literature, additional acupuncture care is medically necessary. 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 acupuncture and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested interpersonal neurobiology therapy for treatment of the enrollees behavioral health condition.  The physician review found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Low intensity disruptive behavior is found in both healthy and disruptive preschoolers, which is defined as losing of the temper and low intensity property destruction.  It is not necessarily a predictor of school age conduct disorder.  There is a range of these behaviors which would be described as normal for this age group.  These same behaviors are described in her consultation, which are moderate in intensity, occurring once per day.  The documentation does not address how interpersonal neurobiology therapy materially differs from standard treatment modalities for a child this age with this intensity of disruptive behavior.  The records do not demonstrate that this patient requires interpersonal neurobiology therapy as opposed to traditional modalities.  All told, the requested interpersonal neurobiology 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested individual weekly psychotherapy services for treatment of her posttraumatic stress disorder.  The physician reviewer found that trauma-focused psychotherapeutic interventions represent the gold standard treatment for individuals diagnosed with posttraumatic stress disorder.  Cognitive processing therapy and prolonged exposure in particular demonstrate enduring treatment gains and robust remission rates.  In reviewing the record, there was mention of eye movement desensitization and reprocessing, which is an evidence-based therapy.  However, there was no documentation regarding the specifics of the intervention.  Based on the documentation provided, the patient has not been treated with an evidence-based psychotherapy for the diagnosis of posttraumatic stress disorder.  Such therapies are steeped in cognitive behaviorism which may further benefit the patient as they are proven interventions for clinical depression as well.  The relevant peer-reviewed literature and current practice guidelines indicate that a 12-week course of trauma-focused behavioral treatment for posttraumatic stress disorder provided by a subject matter expert is sufficient to sustain improvement for up to five years.  In sum, the medical necessity of individual weekly psychotherapy services with an indefinite end date has not been established.  However, an initial course of 12 weekly individual psychotherapy sessions is medically indicated for the treatment of this patient.  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 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 air ambulance transportation for treatment of the enrollees eating disorder.  The physician reviewer found that the records indicate that this patient had failed treatment programs in her region, and was referred to a higher level of care, an inpatient treatment program in another region. The patient had a history of behavior that eliminated transport via commercial aircraft as an option. Ground transportation via ambulance was also an unreasonable option in this clinical setting. The patient continued to have clinical medical deterioration, thus her medical providers noted that treatment at the out of region program was imperative. For these reasons, the air ambulance transportation was medically necessary for treatment of this patients medical condition. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a continuous passive motion (CPM) machine for treatment of his medical condition status post total knee replacement surgery.  The physician reviewer found that review of the recent literature as reported by Harvey and colleagues suggests that there was moderate quality evidence to indicate that CPM does not have clinically important short-term effects on active knee flexion range of motion improvement. In addition, Denis and colleagues conducted a randomized controlled clinical trial to compare the effectiveness of three inpatient rehabilitation programs with and without CPM for range of motion in knee flexion and knee extension, functional ability, and length of stay after primary total knee arthroplasty. The authors found that the results of the study do not support the addition of CPM applications to conventional physical therapy after primary total knee arthroplasty as applied in this clinical trial. In light of the foregoing, the postoperative use of CPM is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the device at issue was 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an evaluation for an oral appliance and an oral appliance for treatment of his obstructive sleep apnea. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services and equipment.  In this patients case, he does not have clinically significant obstructive sleep apnea that requires treatment.  If there is concern regarding positional changes of supine sleep, using a vest or shirt with a tennis ball sewed into the garment would prevent supine sleep.  There is no indication for the requested oral device in this clinical setting.  All told, the requested evaluation for an oral appliance and an oral appliance are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services and equipment 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 internal medicine with sub-specialty certification in pulmonary disease 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 right ventriculoperitoneal shunt placement with laparoscopic placement of peritoneal catheter for treatment of her hydrocephalus.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has Down syndrome and worsening hydrocephalus.  Per the records, a recent computed tomography (CT) scan demonstrated worsening hydrocephalus.  The patient has been declining neurologically at the same time that her hydrocephalus is radiologically worsening.  She has had a trial of lumbar puncture with clinical improvement.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested right ventriculoperitoneal shunt placement with laparoscopic placement of peritoneal catheter 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 neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Aubagio for treatment of his multiple sclerosis. The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. This patient presents with multiple sclerosis and has tried two injectable drugs with reported side effects. He has been stable with treatment of Aubagio for two years.  Aubagio is U.S. Food and Drug Administration approved for relapsing forms of multiple sclerosis. There is medical literature supporting Aubagio as effective at reducing relapses, MRI activity and slowing disability progression. In this case, treatment with Aubagio appears to be effective for this patient. Based on the medical literature and clinical documentation provided, the request for treatment with Aubagio is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She was medically stable.  She was not functionally or cognitively impaired.  With the exception of adding one medication, her medications had not been changed since admission.  Her family was supportive and participated in family sessions.  She was active in her therapies.  It was not medically necessary for the patient to remain in a 24-hour, supervised residential setting.  All told, residential treatment center services provided during the period at issue were not medically necessary for the treatment of this patient.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 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 requested robotic repair/replacement of the mitral valve for treatment of his mitral valve disease.  Findings:  The physician reviewer found that the gold standard for mitral repair and replacement procedures is a midline sternotomy approach. It is the time-tested procedure with which all others must be compared.  Although some of the incisions are smaller, the overall robotic procedure will often become much more invasive to the patient physiologically due to longer bypass times and longer operations. Based on the medical literature and clinical documentation provided, the request robotic repair/replacement of the mitral valve is not medically necessary for treatment of the 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 general surgery with sub-specialty certification in thoracic 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.