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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Cologuard stool testing. Findings:  The physician reviewer found that there is a lack of support in peer reviewed evidence based literature for the superior efficacy of the services at issue when compared to the conventional options of evaluating this patients medical condition. The conventional assessment of colorectal cancer risk largely involves detection of non-dysplastic adenomatous polyps. Toward this end, the efficacy of computed tomography (CT) colonography, of the Cologuard assay, and of detection of occult blood in stool is traditionally compared against the gold standard, optical colonoscopy. The records do not document a contraindication by this patient to optical colonoscopy. Given the low sensitivity of Cologuard in detecting adenomas, the assay is not as beneficial as any established alternatives in this patients case. The available records do not support that more effective conventional screening strategies are contraindicated in this patients case.  As such, Cologuard testing was not likely to have been of greater benefit when compared to other methods of evaluating this patients medical condition. Final Result: Two of the three reviewers determined 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 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 authorization and coverage for Zepatier. According to the most recent joint guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including Zepatier, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as 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 Avastin. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees stage IV colon cancer.The request for Avastin is medically necessary for treatment of the patients medical condition. In this case, the patient presents with stage IV colon cancer and has completed 12 cycles of chemotherapy with FOLFIRI and then capecitabine both in conjunction with Avastin. Avastin was then continued as maintenance therapy. The use of single agent Avastin after use in combination with chemotherapy is considered a standard of care for patients with stage IV colon cancer. In addition, it is supported by the National Comprehensive Cancer Network (NCCN) guidelines and the peer-reviewed literature. For the reasons provided, treatment with Avastin has been established as 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 internal medicine with sub-specialty certification in medical oncology and hematology 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: A 59-year-old male enrollee has requested authorization and coverage for a positron emission tomography (PET) scan with computed tomography (CT) attenuation for evaluation of the enrollees rising prostate specific antigen (PSA).  Findings:  The physician reviewer found that This patient has biochemical evidence of tumor recurrence despite radical prostatectomy and radiation therapy given the PSA of greater than 0.40. It is important to examine the prostate bed as well as the pelvis to determine the nature of the tumor recurrence in order to offer the best treatment. Fluciclovine or Axumin PET/CT has proven to be more efficient and specific than the previously accepted technique, C-11 Choline. Thus, in this patient with biochemical failure and evidence of recurrent prostate cancer, the most efficacious test is Axumin otherwise known as fluciclovine PET imaging. Accordingly, the requested PET scan with CT attenuation is supported as medically necessary for evaluation of this patients medical condition. 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 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 Zepatier 50 mg-100 mg for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus.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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier 50 mg-100 mg for 12 weeks is medically necessary for the treatment of the 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: The parent of a seven-month-old male enrollee has requested authorization and coverage for a cranial helmet/doc band including molding and fitting for treatment of the enrollees plagiocephaly.  Findings:  The physician reviewer found that Since the back to sleep campaign was recommended by the American Academy of Pediatrics (AAP), there has been an increase in the incidence of positional plagiocephaly in infants (Trachtenberg, et al). Tamber and colleagues reviewed 15 studies on the treatment of positional plagiocephaly in infants and concluded that there is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Roby and colleagues evaluated 1,045 teenagers born after the introduction of the back to sleep recommendation and found persistent plagiocephaly in only 1.1% and brachycephaly in 1%, compared with the estimates of 20-48% incidence in infants, suggesting that positional plagiocephaly may self-correct over time. Given this support, the requested cranial helmet/doc band including molding and fitting is medically necessary for treatment of this 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 upheld. Credentials/Qualifications: The reviewer is board certified in pediatrics and neurology with special qualification in child 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: The parent of a two-year-old female enrollee has requested authorization and coverage for occupational therapy, feeding therapy and physical therapy. Findings:  The physician reviewer found that the request for occupational therapy, feeding therapy and physical therapy are medically necessary for the treatment of the patients medical condition. There is sufficient medical literature supporting the requested services in this clinical setting. According to studies, Current conventional treatment of autism spectrum disorder (ASD) in children includes intensive behavioral interventions (known as applied behavioral analysis or ABA), rehabilitative services such as speech therapy, occupational therapy, physical therapy, social skills training, and counseling. Studies find that for children with autism spectrum disorder, Goals should include improved functional verbal and nonverbal communication and social skills, increased engagement in developmentally appropriate activities, improved fine and gross motor skills, and the development of independent academic and organizations skills, as well as replacement of problem behaviors with developmentally appropriate behaviors. In addition, studies describe the importance of feeding therapy in children with autism spectrum disorder. Affected children often have severely restrictive diets. Given the support cited above, the request for occupational therapy, feeding therapy and physical therapy are medically necessary for treatment of the patients moderate-to-severe autism spectrum disorder. 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 and neurology with special qualification in child 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: The enrollee is requesting services for one-on-one psychologist visist once a week for two to three months. Findings: The physician reviewer found that there is support in the documentation for the requested services in this clinical setting. In general, the standard of care for treatment of patients in crisis require frequent therapy sessions. In this case, the patient was recently diagnosed with bipolar type 1. The patient was hospitalized due to suicidal ideation and after a manic episode. Accepting the diagnosis of bipolar and staying compliant with treatment is a challenge for many newly diagnosed patients with bipolar type 1 disorder. The patient continued to be anxious and continued to have difficulty with school and family. The patient is requesting weekly therapy sessions for two to three months to help him through this transition period. Based on the records provided, this patient is likely to benefit from weekly therapy sessions for up to three months to help him through this transition period and to stay compliant with treatment. Therefore, one-on-one psychologist visit once a week for two to three months are medically necessary for treatment of this patients medical condition. Given these findings, the requested services are medically necessary for treatment of this 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: In the medical literature, a study found that for patients with chronic non-cancer pain, short and long acting opioids have been found to be effective. The authors noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. A study reported that opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerability. This patients records document that the use of tramadol was too strong, which would rule out the use of a tramadol extended release. In addition, considering the patients history of dysphagia, the use of an oral medication should be avoided when possible. Evaluating the use of buprenorphine patch conversion factor, the 5 mcg per hour in a 24-hour patch every week converts to 9 mg morphine a day. Thus, the current buprenorphine patch dosing regimen is supported as appropriate for this patient with appropriate follow-up including urine drug monitoring by his provider. Accordingly, the requested buprenorphine patch is medically necessary for treatment of this 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 upheld. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: There is support in the documentation for the medical necessity for a portion of the requested services. According to the submitted records, the patient has a diagnosis of borderline personality disorder and DBT is the gold standard for treatment of this condition. DBT is evidenced-based treatment, which was initially designed for adults. However, this model has been adapted for treatment of adolescents who are diagnosed with borderline personality disorder. The medical literature recommends a length of treatment from 24 weeks to 16 weeks for adolescents in order to increase the likelihood of commitment. Family therapy is also included in the adolescent DBT model. There is support for DBT for adolescents diagnosed with borderline personality disorder. In this case, the patient is likely to benefit from the adolescent DBT model. For these reasons, a portion of the requested services is medically necessary. Specifically, weekly individual therapy sessions through an intensive outpatient dialectical behavior therapy program for 16 weeks is medically necessary. Given these findings, a portion of the requested services is medically necessary for treatment of this patients medical condition. 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 with expertise 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: A 29-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the lumbar spine. Findings:  The physician reviewer found that the requested service is not medically necessary for evaluation of the patients medical condition. According to the documentation submitted for review, radiographs demonstrate degenerative changes including facet arthropathy at L5-S1. A neurological examination indicated there were no fractures present or history of trauma, malignancy, or absent reflexes. The patient began physical therapy for treatment of lower back pain. Given that the patient has not completed a six-week trial of conservative management such as physical therapy, the request for MRI of the lumbar spine has not been established as medically necessary for evaluation of the patients back pain. Final Result: The reviewer determined that the requested service 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: The enrollee has requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) services. The Health Plan has denied this request indicating that the services at issue were not and are not medically necessary for treatment of the enrollees behavioral health condition.Findings: There is sufficient support for the services at issue in this clinical setting. The record notes that the patient continued to be symptomatic. The patient was documented as having persistent depressive and anxiety symptoms. The patient reported suicidal ideation without a plan, poor sleep, and she continued to present with urges to self-harm. The patients parent noted that the patient continued to have poor emotion regulation, difficulty with sleep and appetite and was socially isolative from friends and family. The American Academy of Child and Adolescent Psychiatrys (AACAP) Child and Adolescent Service Intensity Instrument (CASII) were developed to help determine the appropriate level of service intensity for behavioral health treatment for youth.  The CASII utilizes dimensions that are relevant to the youths clinical status when determining appropriate level of service intensity.  These dimensions include risk of harm, functional status, co-occurrence, environmental stress, environmental support, resiliency and/or response to services, child/adolescent involvement in services, and parent involvement in services. Based on the patients clinical history and documentation as outlined above, the PHP level of care provided were and are medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that services at issue were and 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 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 authorization and coverage for bilateral Synvisc One injections. There is adequate 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. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which 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. This patient reports consistent relief with hyaluronic acid injections. All told, the requested bilateral Synvisc One injections are supported as medically necessary for treatment of this patients knee osteoarthritis.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.