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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for brachytherapy provided for treatment of the enrollees breast cancer. Findings: All three physician found that the submitted documentation supports the services at issue in this clinical setting.  Accelerated partial breast irradiation (APBI) is considered an acceptable standard treatment for patients with early stage breast cancer meeting stringent criteria. This patient meets ABPI criteria set by the American Society for Radiation Oncology. APBI may be delivered using external beam radiotherapy, brachytherapy, or intraoperative radiation therapy. In this particular patient, the use of IORT also allowed her to finish her breast cancer treatment up to six weeks earlier versus conventional whole breast fractionated photon therapy, and thus begin chemotherapy for her multiple myeloma sooner. In sum, brachytherapy provided was likely to have been more efficacious than other available treatment alternatives. Final Result: All three physician reviewers determined that the services at issue were 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: All three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewer 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 authorization and coverage of Cinqair infusion for treatment of the enrollees severe persistent asthma. Findings:  The physician reviewer found that the documentation provided fails to demonstrate the medical necessity of the requested medication in this clinical setting. The submitted progress notes from the ordering provider do not list any medications. The progress notes list no chief complaints, no physical examination and no past medical history.  The progress note indicated that the patient presented with cough, wheeze, shortness of breath and sneezing while on Advair 500, montelukast, Spiriva, theophylline and prednisone.  However, there are no other progress notes to support that the patient continued to experience uncontrolled flare up while on the medication regimen.  There is a lack of documentation across a longer span of time to show that the patient has tried and failed the formulary medications, or that she has experienced uncontrolled flare up while being compliant with these medications.  As such, Cinqair infusion is not medically necessary for treatment of this 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 allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MasterGraft Filler for treatment of his severe stenosis and neurological deficits with myelopathy. Findings: The physician reviewer has found that the request for MasterGraft Filler has not been established as medically necessary for treatment of the patients medical condition. The use of MasterGraft bone void filler is to be gently packed into bony voids or gaps of the skeletal system. These defects may be surgically created through osseous defects or osseous defects created from traumatic injury to the bone. However, the use of the MasterGraft bone void filler remains controversial and is not the standard of care. There is a lack of peer-reviewed literature supporting its use in this clinical setting. Given the lack of support in the peer-reviewed literature, the requested service is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for advanced surface ablation (photorefractive keratectomy) for treatment of the enrollees blurry vision. Findings:  The physician reviewer found that hyperopia and astigmatism can develop following refractive surgery. Refractive surgery is an accepted treatment for hyperopic astigmatism. In this case, there is no evidence of medical contraindications to wearing glasses or contacts. Thus, refractive surgery is not indicated for this patient. Accordingly, the requested advanced surface ablation (photorefractory keratectomy) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested service 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 ophthalmology 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 acupuncture for treatment of her neck pain.Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient reports neck pain of six years duration.  Her prior treatment has included physical therapy, massage, and chiropractic care.  The study by Konig and colleagues showed that acupuncture is superior to conventional massage, dry needling of local myofascial trigger points, and sham laser acupuncture, for improving active range of motion and pain in patients with chronic neck pain, especially in patients with myofascial pain syndrome. As this patient remains symptomatic despite previous care, an acupuncture trial for pain management and function improvement is supported by the peer-reviewed literature. All told, the requested acupuncture is medically necessary 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 oriental 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 reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that regarding her recovery environment, the patient has a moderately stressful environment, and the records support a score of 3. The patients husband is supportive of the patient. The patients mother died six months prior to admission, which she reports was a distressful circumstance. In terms of level of support, the records support a score of 2.  The patient has a supportive environment, as her husband is supportive. Regarding treatment history, the documentation supports a score of 3.  The patient has had limited prior treatment. She participated in Alcoholics Anonymous, and this was unsuccessful to curb her drinking. In terms of engagement and recovery status, the records support a score of 3.  The patient appears to want to engage in treatment and desires to recover. However, notes report that she is in the contemplative stage and may lack confidence to change despite  intentions to do so.  She is able to develop a positive relationship with her providers, but appears to have some uncertainty in acceptance of her illness. Therefore, the records support a total score of 20.  Based on these criteria, the patient meets criteria for a partial hospitalization program. All told, residential treatment center services were not and are not medically necessary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni for the treatment of the enrollees hepatitis C. 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. In non-cirrhotic, genotype 1 patients who have failed Sovaldi and ribavirin, the guidelines recommend re-treatment with Harvoni and ribavirin.  However, when ribavirin has to be discontinued, as in this case, re-treatment with Harvoni monotherapy has been studied and found to be effective. For these reasons, the requested therapy with Harvoni to complete therapy is medically indicated.  All told, the requested extension of the medication, Harvoni is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 Harvoni one tablet daily for a duration of 12 weeks for treatment of her hepatitis C. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  All told, Harvoni one tablet daily for a duration of 12 weeks is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the residential treatment center services are medically necessary for treatment of the patients medical condition. Bipolar disorder represents a severe mental disease that has poor outcomes and an exceedingly elevated suicide rate. The risk of suicide is even higher for previous attempters and substance users. Thus, this patient is at-risk for a poor clinical outcome. Based on the documentation provided, she has not found the optimal psychotropic medication regimen. Residential placement is indicated to allow the patient to consolidate treatment gains and develop coping skills to manage her anger. The treatment team had yet to hear back from previous providers for collateral information and aftercare planning. The patient was angry and experiencing aggressive ideation with thoughts of self-harm. She did not like her university and had no firm plan in place for the summer or following semester. A family session was planned. With the strained parent-child dynamics, a hasty discharge to home would have likely been unsuccessful, and likely resulted in prompt readmission. Considering the relevant history and peer-reviewed literature, residential treatment is safe, appropriate and consistent with good practice and reasonably expected to improve the patients condition and prevent a more serious episode of illness in this case. Therefore, the requested services are medically necessary for treatment of the patients behavioral health 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets for 12 weeks for treatment of hepatitis C.  Findings:  The physician reviewer has found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated, except those with limited life expectancy due to non-liver-related conditions. 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 Zepatier for 12 weeks when NS5A resistance is not found, and Zepatier with ribavirin for 16 weeks when NS5A resistance is present (as in this patients case). These guideline recommendations are based on clinical trial results showing a 58% cure rate with Zepatier for 12 weeks when NS5A resistance is present.  When NS5A resistance is present, Zepatier and ribavirin for 16 weeks is recommended by the guidelines. For these reasons, although treatment is needed regardless of fibrosis stage, Zepatier 50/100 mg tablets for 12 weeks is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old male enrollee has requested authorization and coverage for individual and group speech therapy for treatment of the enrollees expressive language disorder.  Findings:  The physician reviewer found that the request for individual and group speech therapy is not medically necessary for this patient. According to colleagues there is some evidence that social skills groups can improve social competence for some children and adolescents with ASD although the study underscores that more research is needed to draw more robust conclusions, especially with respect to improvements in quality of life. Another systematic review on the subject indicates that Social skills interventions presently appear modestly effective for youth with ASD, but may not generalize to school settings or self-reported social behavior. In sum, the data on the efficacy of social skills groups in autism appears to be emerging. In this case, the patient has demonstrated significant improvement in speech therapy in the areas of expressive communication skills. The majority of the patients delays in communication skills are likely due to behaviors associated with ASD, and these are best addressed in the context of ABA. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition. 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has reimbursement for advanced lipoprotein testing (CPT 83704). Findings:  The physician reviewers found that there is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology (ACC) do not support the use of advanced lipoprotein testing. According to the ACC, there is a lack of data to indicate a benefit for advanced lipoprotein testing over the basic lipid profile. Rather, the guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing (CPT 83704) performed was not likely to have been more beneficial than the standard testing options for the evaluation of this patient. Final Result: 2 of 3 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 internal medicine with sub-specialty certification in cardiovascular disease 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 act internal medicine with sub-specialty certification in cardiovascular disease 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 authorization and coverage for osteochondral allograft transplant treatment of the enrollees knee pain. Findings: Three physician reviewers found that this patient presents with persistent significant right knee pain and swelling. Functional difficulty is documented in activities beyond basic activities of daily living. Clinical examination findings are consistent with imaging evidence of a large osteochondral lesion, measuring well over 4 square centimeters, of the medial femoral condyle. He was status post multiple ACL reconstruction procedures, with the treating provider reporting the current ACL deficiency is correctable. There was mild to moderate medial joint space narrowing documented with neutral alignment. Evidence of a recent, reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. This request for osteochondral allograft (OCA) transplantation has been recommended as an option to avoid total knee replacement given the patients young age. There is peer-reviewed literature support for OCA transplantation in this situation. Therefore, the requested osteochondral allograft transplant is likely to be more effective than other available treatment options. Final Result: The reviewers determined that the requested services 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: The three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewer are 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.