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 to add intravenous (IV) morphine to the emergency treatment protocol for treatment of her migraine headaches. Migraine is a frequent chief complaint leading to presentation to acute care. Researchers have noted that while opioids are frequently used as a migraine abortive agent, evidence suggests that this is not the most effective agent and that it can lead to potential chronic migraine and other headache disorders including medication overuse headache. Several therapies have been compared with opioid analgesia and have shown to be superior, including, but not limited to, dihydroergotamine, ketorolac, butyrophenone, and phenothiazines. Additionally, researchers have found that there is evidence to suggest that opioid analgesia may decrease response to more appropriate migraine abortives such as triptans. Therefore, the addition of IV morphine to the patients emergency treatment protocol for treatment of her migraine headaches is not medically necessary for treatment of her 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medication Mavyret 40mg-100mg, three times daily, for eight weeks. The submitted documentation supports the medical necessity of the requested medication. 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 2 patients should be treated with Mavyret for 8 weeks. These recommendations apply regardless of fibrosis stage. The SURVEYOR-II trial showed a 99% cure rate with 8 weeks of treatment. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 40mg-100 mg, three tablets daily, for eight weeks is medically necessary for the 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 internal medicine, with subspecialty 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 Otezla. The submitted documentation supports the medical necessity of the requested medication. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease. The long-term use of traditional systemic therapies is frequently unacceptable because of renal, hepatic, pulmonary toxicity and limited efficacy. Traditional systemic therapies for psoriasis, including methotrexate and cyclosporine, have a well-documented array of toxicities, particularly end-organ toxicities. Over the past several years, the use of anti-tumor necrosis factor biologic therapies for the treatment of moderate to severe psoriasis has been a major clinical and research focus. Despite several difficulties with documenting risks, some systemic treatments for psoriasis have been linked with an increased risk of selected cancers. In addition, patients treated with anti-tumor necrosis factor drugs may develop adverse events such as infections, acute infusion and injection reactions, autoimmunity and cardiovascular effects. It has been well-documented that therapies of psoriasis with injectable biologics increase the risk for malignancy and infection, mandating prior testing for tuberculosis. Apremilast (brand name Otezla), an oral PDE4 inhibitor, provides a novel therapeutic option for the treatment of patients with moderate to severe plaque psoriasis. Its effects on cyclic adenosine monophosphateregulated intracellular signaling, gene expression, and subsequent protein levels allow apremilast to modulate the immune responses that cause the inflammation associated with psoriasis. In this case, the patient has chronic plaque psoriasis with joint involvement that requires systemic treatment. The immunosuppressant and anti-tumor necrosis factor drugs recommended by the Health Plan can increase the risk for infection and malignancy. The medical evidence supports Otezla in this clinical setting. Therefore, Otezla 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 dermatology 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 Orthovisc injections. The submitted documentation supports the medical necessity of the requested services. The current literature continues to support the use of viscosupplementation for osteoarthritis of the knees. Per medical literatures, there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Evidence from real-life studies of repeat courses of intraarticular hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months, a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around 2 years. The researchers performed a systematic review of overlapping meta-analyses comparing viscosupplementation with other nonoperative treatment modalities for knee osteoarthritis. Their review found that that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for knee osteoarthritis and that its use results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. There is sufficient support for the requested services in this clinical setting. Therefore, Orthovisc injections 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Guardant360 diagnostic laboratory testing. Findings:  Two of the three physician reviewers found that molecular diagnostic studies in non-small cell lung cancer are considered a standard of care. Numerous gene alterations have been identified that impact therapy selection. The National Comprehensive Cancer Network (NCCN) strongly advises broader molecular profiling with the goal of identifying rare driver mutations for which effective drugs may already be available, or to appropriately counsel patients regarding the availability of clinical trials. Broad molecular profiling is a key component of the improvement of care of patients with non-small cell lung cancer. Testing of lung cancer specimens for these alterations is important for identification of potentially efficacious targeted therapies, as well as avoidance of therapies unlikely to provide clinical benefit. Therefore, Guardant360 diagnostic laboratory testing was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers determined that the services at issue were 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 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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 authorization and coverage for weekly individual psychotherapy services. The submitted documentation supports the medical necessity of the requested services. A review of randomized trials of adjunctive psychotherapy for bipolar disorder concluded that, [A]djunctive psychotherapy enhances the symptomatic and functional outcomes of bipolar disorder. A review of outcome studies of psychological interventions noted that, `[B]ipolar disorder is often only partially treated by medication alone ... a range of psychological approaches appear to benefit people with bipolar disorder.` These studies reflect that psychotherapy has been shown to help reduce patients symptoms in the context of bipolar disorder. Like any other treatment, however, psychotherapy needs to be continued for maintenance, as bipolar disorder is not curable, but is at least manageable and treatable. The standard of maintenance psychotherapy is weekly, which is appropriate to treat the patients condition, and is consistent with good medical practice. Accordingly, weekly individual psychotherapy 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement for Intensive Outpatient Program (IOP) services. The American Academy of Child and Adolescent Psychiatry and the American Association of Community Psychiatrists Child and Adolescent Level of Care Utilization System (CALOCUS) provides a reliable framework for determining the appropriate level of care for adolescents needing mental health treatment. Using CALOCUS, providers score patients on a scale of 1-5 using a six-pronged Dimensional Rating System. The six dimensions include: (1) risk of harm; (2) functional status; (3) medical, addictive and psychiatric comorbidity; (4) recovery environment (a. stressors and b. supports); (5) treatment and recovery history; and (6) engagement. The composite score is then used to determine the level of care needed. Per CALOCUS, intensive outpatient program treatment level of care requires a composite score of at least 17.For a CALOCUS composite score of 19, the recommended level of care is intensive outpatient therapy. Therefore, Intensive Outpatient Program (IOP) services were medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for phrenic nerve repair. Findings: Two of the three physician reviewers found that there is a lack of support for the requested services in this clinical setting. The requested services may be appropriate for patients with specific indications, such as phrenic nerve injury after cervical trauma, following thoracic surgery, following cardiac surgery or following central line insertion and injury. Further indications include vascular compression in the neck or mediastinal abnormality causing compression or injury to the phrenic nerve. In this patients case, the records do not document these indications for phrenic nerve repair. In sum, the requested phrenic nerve repair is not likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested services are 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 physician reviewers are board certified in thoracic and cardiac surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Synvisc One injection. The submitted documentation fails to demonstrate the superior efficacy of the requested services in this patients case. Hyaluronic acid injections in the knee are recommended as a possible option for patients with severe osteoarthritis who have not responded adequately to recommended conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. While medial and/or lateral compartment osteoarthritis is a recommended indication, there is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patella-femoral syndrome (kneecap pain), or osteochondritis dissecans. Hyaluronic acid injections are not recommended for chondromalacia patella. This patient presents with chronic right knee pain. Clinical examination findings have demonstrated positive patellar grind consistent with imaging evidence of chondromalacia patella. Conservative treatment has included corticosteroid injection, without sustained benefit. The records document chondromalacia patella. The clinical notes do not document evidence-based indications for this treatment, including medial and/or lateral compartment osteoarthritis. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of Synvisc One for this patients condition. Therefore, Synvisc One injection is not likely to be of greater benefit than other treatment options.Findings:  Two of the three physician reviewers found the requested services are 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.Final Result: The reviewers determined that the requested medication is 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 1, 2 and 3 are board certified in orthopedic surgery 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 authorization and coverage for MRI of silicone breast implants. The U.S. Food & Drug Administration (FDA) recommends that persons who have silicone gel-filled breast implants receive MRI screening for silent rupture 3 years after receiving their implant, and every 2 years after that. A study found that MRI is the modality of choice, if it is available. Their study found that the diagnostic accuracy of magnetic resonance imaging was significantly higher than that of ultrasound (94 percent versus 72 percent; p < 0.0001), and states, [M]agnetic resonance imaging should be considered the investigation of choice for implant rupture where the resource is available. However, if magnetic resonance imaging is contraindicated or unavailable, ultrasound can be considered as an alternative method. In this case, the patient has previously undergone bilateral mastectomy and reconstruction with silicone implants for a left breast cancer. Due to a past silent rupture found on MRI, she underwent implant exchange with silicone implants. At this time, the patient's current silicone implants have not received MRI screening for silent rupture in seven years. Based on the entirety of the medical documentation, MRI of silicone breast implants is medically necessary for treatment of the patients medical condition at this time.Final Result: The reviewer determined that the requested service 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for percutaneous tibial nerve stimulation (PTNS) (procedure code 64566).Findings:  Two of the three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting. PTNS is an appropriate treatment for overactive bladder. The treatment is minimally invasive, repeatable and can be adjusted in its application to treat patients according to symptoms. It does not preclude the use of other forms of treatment. In more severe cases of overactive bladder syndrome, PTNS may need to be used in combination with overactive bladder medications in order to resolve symptoms. This patient experienced symptom relief with the use of PTNS. Therefore, PTNS was and is likely to be more effective than other treatment options. Final Result: The reviewers determined that the services at issue were and 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: Physician reviewers 1, 2 and 3 are board certified in urology 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a blood test.Findings:  Two of the three physician reviewers found that statins are a class of lipid-lowering medications which reduce the risk of cardiovascular disease. However, these medications have been associated with side effects, including muscle pain, increased risk of diabetes mellitus, and abnormalities in liver enzyme tests. Providers occasionally measure other markers, such as lipoprotein (a), in order to help determine if a patient is at increased risk of coronary artery disease and may benefit from statin therapy. However, there is a lack of effective medications to lower lipoprotein (a) applicable to large population groups, preventing intervention studies for the reduction in cardiovascular disease endpoints, and many patients may have cardiovascular disease despite a very low lipoprotein (a) level. Many experts recommend only measuring lipoprotein (a) in patients with unexplained premature coronary artery disease, patients with a strong family history of premature heart disease, patients with resistance to low-density lipoprotein (LDL) lowering with statins, patients with rapid unexplained progression of atherosclerosis, and patients with familial hypercholesterolemia. This patient does not meet these criteria. Therefore, the blood test was not likely to have been more effective than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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

enrollee has requested authorization and coverage for a referral to see a pulmonologist. The Pulmonary Hypertension Association (PHA) recommends including a pulmonologist in the treatment of patients with pulmonary hypertension. Here, the patient is noted to have multiple pulmonary issues including pulmonary hypertension, tuberculosis and an abnormal chest xray. Given this patients medical history and per PHA guidance, a referral to a pulmonologist is medically necessary for this patient.