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

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of the enrollees left knee pain. Findings:  The physician reviewer found that the requested MRI is the appropriate method for the evaluation of this patients chronic knee pain status post fall. MRI is the current gold standard for the assessment of soft tissue, chondral, and bony pathologies of the knee joint. In this case, the patient has chronic knee pain with recurrent effusions. Physical examination shows a joint effusion and medial joint line tenderness. McMurray is plus or minus and there is no instability. X-rays have been negative for bony trauma and do not show osteoarthritis. As such, additional diagnostic testing is necessary to evaluate from the viewpoint of arthroscopy. The MRI scan is accurate for the diagnosing meniscal tears and remains the gold standard. Consistent with the current medical literature, the requested MRI is medically necessary for further evaluation of this patients knee pain. 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 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 Oncotype DX testing for evaluation of the enrollees newly diagnosed breast cancer. Findings:  2/3 of the physician reviewers found that the patient has invasive ductal carcinoma, invasive breast cancer, in addition to surrounding DCIS ductal carcinoma in situ (DCIS). Early breast cancer that is hormone receptor positive can be treated with tamoxifen alone in postmenopausal women. In this case, there is a 15% chance of recurrence. It is this 15% that needs adjuvant chemotherapy. More recently, the Oncotype DX has been included in the guidelines of the American Society of Clinical Oncology (ASCO) for biomarker analysis. The analysis of the ASCO panel states that Although performed retrospectively, the validation of this assay using a prospectively collected clinical trial data set, but retrospectively collected tissues from the data set, might be considered as Level of Evidence I for use of this assay. In addition, there is sufficient support in the peer-reviewed literature for Oncotype DX in post-menopausal patients. In this case, its use was clinically indicated and appropriate. Therefore, the Oncotype DX testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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: A female enrollee has requested authorization and coverage for the balloon sinus ostial dilation for treatment of the enrollees nasal obstruction and chronic sinusitis. Findings:  The physician reviewer found that at present, functional endoscopic sinus surgical techniques for the management of recurrent acute and chronic rhinosinusitis which are refractory to medical management are still considered the surgical treatment of choice. This patient reportedly had symptoms of recurrent acute rhinosinusitis with multiple episodes that was partially controlled with medications, but the symptoms recurred. The physical examination and CT imaging confirmed evidence of nasal septal deviation and mucous membrane thickening within the maxillary sinus with presence of a sinus cyst. However, the patient had no evidence of frontal sinus disease based on the history and on the imaging studies. The provider recommended standard endoscopic image-guided sinus surgery and nasal septal reconstruction, but did not mention the clinical addition of balloon sinus ostial dilation of the frontal and maxillary sinuses. Surgical endoscopic sinus surgery addresses the ethmoid and maxillary sinuses such that the clinical addition of a balloon is not indicated to manage the patients symptoms. Thus, the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two of the reviewers determined that the requested procedure is 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: Physician reviewer number one is board certified in otolaryngology 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.Physician reviewer number two is board certified in otolaryngology 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.Physician reviewer number three is board certified in otolaryngology 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 morphine 45 mg three times daily and Dilaudid 4 mg for breakthrough pain for treatment of the enrollee who has a history of chronic pain, progressive multiple sclerosis, and chronic abdominal pain.Findings:  The physician reviewer found that the step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative settings. The Centers for Disease Control and Prevention (CDC) also states when opioids are started, providers should prescribe the lowest effective dosage. These guidelines recommend that providers should use caution when prescribing opioids at any dosage and to carefully reassess evidence of individual benefits and risks when considering increasing dosage of 50 or more MME per day. It is further recommended that providers should avoid increasing dosage to 90 or more MME per day. In this case, there is no evidence of an objective treatment goal for pain and function supporting the requested medications. Moreover, other non pharmacological ways of taking care of the pain have not been performed or addressed. There is no mention of completion of behavior therapy documented despite the pain providers recommendations and much research to support its use. Finally, not all non opioid medications have been optimized. 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 pain management 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 the immunoassay testing (AdMark Phospho-Tau/Total-Tau/A Beta42, Analysis and Interp) performed by Athena Diagnostic for evaluation of the enrollees memory decline.  Findings:  2/3 of the physician reviewers found that the diagnosis of AD is still largely based on exclusion criteria of secondary causes and other forms of dementia with similar clinical pictures. Improved methods of early diagnosis are needed, particularly because drug treatment is more effective in the early stages of the disease. Recent research focused the attention to biochemical diagnostic biomarker) and according to the proposal of a consensus group on biomarkers, three candidate cerebrospinal (CSF) markers reflecting the pathological AD processes, have recently been identified: total tau protein (T-Tau), amyloid beta (1-42) protein (A Beta42), and tau protein phosphorylated at AD-specific epitopes (P-Tau). Several articles in the peer-reviewed literature report reduced CSF levels of A beta42 and increased CSF levels of T-Tau and P-Tau in AD; the sensitivity and specificity of these data are able for discrimination of AD patients from controls. However, the specificity for other dementias is low. According to literature analysis, the combination of the CSF markers and their ratios may significantly increase the specificity and the accuracy of AD diagnosis. Therefore, the immunoassay testing (AdMark Phospho-Tau/Total-Tau/A Beta42, Analysis and Interp) performed by Athena Diagnostic was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: A male enrollee has requested authorization and coverage for Epclusa 400-100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400-100 mg for 12 weeks 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: A male enrollee has requested authorization and coverage for oxycodone/acetaminophen for treatment of the enrollees chronic back pain. Findings:  The physician reviewer found that the records provided for review demonstrate that this patient has tried and failed conservative treatment options including epidural steroid injections for his chronic back pain and sciatica. According to the documents available for review, the patient has demonstrated objective functional improvement on his current regimen without side effects. Moreover, the patient has been appropriately monitored for possible drug aberrant behavior as required for ongoing treatment. Given these findings, the requested oxycodone/acetaminophen 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 overturned. 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: An enrollee has requested authorization and coverage for Orthovisc injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that as evidenced by this patients history of significant benefit from prior injections, the current literature supports the use of viscosupplementation as treatment for osteoarthritis of the knees in this clinical setting. There is good evidence that these injections reduce pain and increase function in knee osteoarthritis and the benefits are long-lasting as compared with intra-articular corticosteroids. One study reported on a systematic review of overlapping meta-analyses comparing hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. The authors found that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis. Furthermore, intra-articular hyaluronic acid has a good safety profile, and its use should be considered in patients with osteoarthritis of the knee. 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of amale enrollee has requested authorization and coverage for 25 hours per week of applied behavioral analysis (ABA) (0365T), and 12 hours per month of supervision (0369T) for treatment of the autism.Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 25 hours per week of ABA (0365T), and 12 hours per month of supervision (0369T) has been established as medically necessary. In this case, the patient has made progress in many areas as evidenced by the progress reports, however he continues to demonstrate significant delays in social skills, behaviors and adaptive skillsets as measured across multiple domains. In addition, the patient continues to have multiple unmet goals and a high level of self-injury at the frequency of 9.6 times per hour. Thus, there is sufficient support for the ABA hours recommended by the patients provider. All told, the requested 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the partial hospitalization program (PHP) services for treatment of the enrollees alcohol use disorder.Findings:  The physician reviewer found that the patient had mild post-acute withdrawal symptoms. He was not a danger to himself or others. He was not manic, psychotic, agitated, or showing impulsivity. He was newly sober, having completed a detoxification protocol, after a history of alcohol use with the longest period of sobriety of three days. He consistently reported poor appetite and sleep, and problems with memory, concentration, and the ability to think, which did not improve. He also consistently reported that he had trouble accepting that he was an alcoholic. However, he diligently worked on assignments, on his relapse prevention plan, and participated in his treatment plan. Despite his CIWA of 5, given the patients excessive drinking history, lack of any sustained period of sobriety, recent altered mental status, and hospitalization. Final Result: The reviewer determined that a portion of the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:A female enrollee has requested authorization and coverage for acupuncture services for treatment of the enrollees back pain. Findings:  The physician reviewer found that Review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain. Also 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. In this case, the patient is significantly symptomatic despite treatment with physical therapy and oral medication. Based on the documentation submitted for review, acupuncture services are supported as 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Viekira Pak for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1b. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. Per the guidelines, treatment naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high quality clinical trials showing cure rates of over 90% and safety and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. 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.