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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier 50/100 mg for 12 weeks.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 nonliver-related conditions regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found, as in this case. These guideline recommendations are based on clinical trial results. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  Final Result: The reviewer determined that I have 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 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 authorization and coverage for dental surgery procedure (CPT code 41899).Findings:  The physician reviewer found that the medical literature supports the use of general anesthesia in this clinical setting. General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment, particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  In a study by Bader and colleagues, the authors evaluated pediatric dental patients between June 2011 and December 2012, who received general anesthesia. The most common indication for general anesthesia was the childs inability to cooperate and undergo dental treatment under local anesthesia. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients.  Treatment can usually be completed in one procedure. This patients medical records demonstrate that she requires extensive dental work. The records also noted that this patients providers had determined that local anesthesia would not benefit this patient due to her medical diagnoses. 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 anesthesiology 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 reimbursement for genetic tests. Findings:  Three physician reviewers found that the patients provider recommended and ordered genetic tests to evaluate which medications were best suited for treatment of this patient. In the records provided, this patient was diagnosed with obsessive compulsive disorder and depression. The patients provider had ordered genetic tests (GeneSight Psychotropic assay) to determine the effectiveness of the patients treatment. However, there is limited clinical evidenced-based data that support the use of genetic tests such as the GeneSight Psychotropic assay for the evaluation of patients diagnosed with obsessive compulsive disorder. Medical studies are lacking to support the effectiveness of these tests over other modalities in guiding treatment for this patients medical condition. 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: All three physician reviewers are board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin 20 mg for treatment of the enrollees short stature. Findings:  The physician reviewer found that the requested medication is medically necessary for treatment of the patients medical condition. The patient has short stature with an adult predicted height that is 3 SDs below the mean for age and gender. His IGF-1 level was normal for age and there is no supporting evidence that he has growth hormone deficiency. In addition, there is no information provided that all other causes of the patients short stature, including nutritional deficiency, underlying systemic disease, and malabsorption, have been ruled out. Thus, based on the documentation submitted for review, it has not established that the request for Nutropin AQ Nuspin 20 mg is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the allergen test (IgG test). Findings:  Three physician reviewers found that food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods. The standard evaluation of food allergy consists of blood IgE level for foods and skin testing. IgE immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens. Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies. A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food. The use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance. Final Result: Three 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in allergy and immunology 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: The parent of an enrollee has requested authorization and coverage for 43 hours per month of direct applied behavioral analysis (ABA) therapy, 9.5 hours per month of supervision and two hours per month of parent training for treatment of the autism. Findings:  The physician reviewer found that the requested services are medically necessary for treatment of the patients medical condition. According a study, ABA therapy started at a younger age provides improvements in cognitive skills, adaptive skills and language skills. The patient has made some progress, but he has only mastered 44% of the functional skills for a child of his age. ABA therapy at the frequency recommended by his provider is clinically indicated for this patient. Therefore, 43 hours per month of direct ABA therapy, 9.5 hours per month of supervision and two hours per month of parent training 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center services provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the substance abuse residential treatment center services provided were not medically necessary for treatment of the patients behavioral health condition. The patient was experiencing mild post-acute withdrawal symptoms. He was not a danger to himself or others. He was medically stable. He endorsed feelings of hopelessness and increased anxiety, however these issues could have been appropriately managed in counseling in an ambulatory setting. He was taking anti-craving medications. There were no emotional, behavioral, or cognitive issues that warranted residential treatment. He was motivated and engaged in his treatment. His family was supportive. In sum, the patient did not require 24-hour monitoring at the residential level of care, and could have safely and effectively been treated at lower 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested left leg ultrasound-guided microfoam sclerotherapy for treatment of the enrollees venous insufficiency.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this clinical setting.  The medical records note a history of bilateral venous insufficiency.  Superficial varicosities of the right leg were previously treated with foam sclerotherapy.  His provider has proposed ultrasound-guided microfoam sclerotherapy to treat his left leg.  Per the information provided for review, ultrasound-guided microfoam sclerotherapy has been proposed to treat the three perforator veins.  The medical evidence supports the treatment of perforator veins in the setting of an active or healed venous ulceration.  However, in this patients case, there is no documentation suggesting this diagnosis.  There is a lack of support for the requested services in this patients case.  All told, the requested left leg ultrasound-guided microfoam sclerotherapy times three 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 vascular 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 for a sleep study for evaluation of the enrollees snoring. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  There is no Epworth Sleepiness Score documenting daytime hypersomnia, which is a cornerstone for a diagnosis of sleep apnea.  Per the medical records, the patient is not obese. There is no documentation of an elevated Mallampati score.  His consistent outstanding symptom is loud snoring, and this is not an indication for a sleep study.  The patients history is inconsistent and has changed since the initial requested sleep study was denied.  The patient indicated that he has difficulty falling asleep.  This is generally not a symptom of clinically significant sleep apnea, since patients with clinically significant daytime hypersomnia usually have decreased sleep latency.  Snoring and sleep onset insomnia are not indications for a sleep study.  All told, the requested sleep study is not medically indicated for the evaluation of this patient.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 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 Xifaxan 550 mg for treatment of the enrollees small intestinal bacterial overgrowth. Findings: The physician reviewer found that the records indicate that this patient has IBS-D and small intestinal bacterial overgrowth. Xifaxan has been proven to be highly effective in small intestinal bacterial overgrowth and in IBS-D for eradication of bacteria and symptom relief (Scarpellini, et al; Pimentel, et al). For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo (Scarpellini, et al). In addition, Xifaxan had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole and levofloxacin (Pimentel, et al; Lauritano, et al). Moreover, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has been demonstrated to be safe and effective in randomized placebo-controlled trials for IBS-D (Pimentel, et al; Schoenfeld, et al). The formulary alternatives required for IBS-D treatment would not address the patients small intestinal bacterial overgrowth, and the formulary alternatives required for bacterial overgrowth treatment would not address IBS-D. For these reasons, the use of Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients IBS-D.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollee's risk for breast cancer.  Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, for this patient who had noted fibrocystic changes, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit than had the examination been done with two-dimensional imaging alone.  All told, digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.Final Result: Two reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested eating disorder intensive outpatient program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that although comprehensive psychiatric and eating disorder specialty services are indicated, the medical records do not demonstrate the medical necessity of intensive outpatient programming.  There was evidence of a plateaued therapeutic response in context of relative medical stability and the absence of an acute psychiatric syndrome.  The care plan noted no physical symptoms, pending laboratory studies or clinical interventions.  The patient elected to discontinue one of her psychotropic medications.  Despite struggling with ongoing binging and purging, she was mostly compliant with her meal plan in program.  Her caloric intake was 1500 to 2000 kcal, which aligned with the recommended intake of 1650 to 1800 kcal.  The patient was 92% of her ideal weight, and her body mass index was in the normal range.  The termination summary noted moderate improvement with improved insight and awareness of her eating disorder.  Considering the treatment history and patient status as described in the termination summary and most recent treatment review note, intensive outpatient program services would not be reasonably expected to improve the patients condition while effective services, including but not limited to psychiatric care, nutritional counseling, mentoring, and individual, family and group therapies, could be safely delivered in the outpatient setting.  Thus, eating disorder intensive outpatient program services were not and are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were not and 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 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 Sovaldi with Ribapak for treatment of the enrollees chronic hepatitis C virus genotype 2. Findings: The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 2 patients, therapy is recommended with Sovaldi/Daklinza or Epclusa. This recommendation is based on the two studies for Sovaldi/Daklinza, and the ASTRAL-2 trial for Epclusa (Wyles, et al; Sulkowski, et al; Foster, et al). Sovaldi and ribavirin (or Ribapak) are no longer recommended. For these reasons, although hepatitis C treatment is indicated, the request for Sovaldi and Ribapak for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications 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 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.