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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sublingual immunotherapy (SLIT) and oral immunotherapy (OIT) for treatment of the enrollees medical condition. Findings:  The physician reviewers found that OIT is a treatment in which food-allergic patients consume gradually increasing quantities of the food to increase their threshold for an allergic reaction. This therapy carries a significant risk of allergic reactions. The ability of OIT to desensitize patients to particular foods is well-documented, although the ability to induce tolerance has not been established. SLIT involves the administration of small drops of allergen extract under the tongue, which is then eventually spit out or swallowed. SLIT therapy for allergic rhinitis carries a significantly less risk for severe systemic side effects given the sublingual route of administration, as opposed to subcutaneous immunotherapy. Recent studies show promising data for the use of immunotherapy in food allergic patients. However, therapies such as OIT and SLIT are not recommended for routine clinical practice. The current standard of care in the treatment of food allergies is allergen avoidance and ready access to self-injectable epinephrine. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in allergy and immunology and 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: The parent of an enrollee has requested sublingual immunotherapy (SLIT) and oral immunotherapy (OIT for evaluation the enrollees peanut allergies. Findings: Two physician reviewers found that SLIT and OIT are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this clinical setting, the current standard of care is food allergen avoidance and ready access to self-injectable epinephrine. Although, recent clinical trials and medical literature show promising data for the use of immunotherapy such as SLIT and OIT for food allergy, there is still conflicting and insufficient evidence in terms of the level of desensitization and immune tolerance, long-term effectiveness, safety, and dosing protocols. Thus, it is not known if the patient would benefit from SLIT or OIT therapy for peanut allergy. Therefore, SLIT and OIT cannot be recommended for routine clinical practice for the treatment of food (peanut) allergy.Final Result: Two 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 three physicians are board certified in allergy and immunology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a five-year-old enrollee has requested additional hours per month of applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings: The physician reviewer found that ABA therapy is medically necessary for the treatment of patients with ASD. Reichow and colleagues found that early and intensive ABA could provide considerable benefits for children with ASD including improvements in cognitive skills, language and adaptive skills. In addition, Orinstein and colleagues found that children with optimal outcome from ASD started ABA between four and five years of age and were receiving 25 hours per week of therapy compared with 18 hours per week for those with high functioning autism. In this case, the patient has reached a number of goals with treatment. However, he has tantrums, although at much lower levels, and still has non-compliance behaviors.  He also has moderate level stereotypy requiring a higher level of ABA hours. The reduction of ABA services often leads to regression and worsening behavior. Thus, a reduction of ABA therapy hours per month as authorized by the Health Plan is likely to cause regression and a return of maladaptive behaviors. Thus, a portion of the requested number of hours per month of ABA therapy, supervision and home care training are medically necessary and appropriate for treatment of the patients ASD. Final Result: The reviewer determined that a portion of the requested services are 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, breasts have been described as dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: All three 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 number one, two, and three are board certified in diagnostic radiology and 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 implantation of a hypoglossal nerve stimulator for treatment of the enrollees medical condition. Findings:  The physician reviewers found that many medical and surgical methods have been proposed in treatment of obstructive sleep over the years.  Invasive surgeries have become less popular, as their efficacy remains in question.  CPAP remains the gold standard, but often fails secondary to lack of patient tolerance and compliance.  The literature indicates that the implementation of the Inspire hypoglossal nerve stimulator for the treatment of obstructive sleep apnea appears promising.  However, there is a lack of independent data establishing the superior efficacy of this treatment. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in otolaryngology and 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 prospective authorization and coverage for residential treatment center services. Findings: The physician reviewer found that 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: The physician reviewer found that the residential treatment center services were not and are not medically necessary for treatment of the patients behavioral health conditions. The documentation submitted for review does not support residential placement. The patient does not have significant post-acute withdrawal symptoms. His last use of substances was 10 days prior to admission. The patient was not a danger to himself or to others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was motivated and recognized the need for help. He was medically and psychiatrically stable. He had support systems in place. The structured, 24-hour setting of residential treatment was not and is not medically necessary in this clinical setting. The patient could have been treated at a lower level of care. Thus, the residential treatment center services provided from were not and are not medically necessary.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 Viekira Pak for treatment of the enrollees hepatitis C virus.   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. Patients with diabetes mellitus are at risk for faster progression 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; the medication is U.S. Food and Drug Administration-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Feld, et al; Poordad, et al; Ferenci, et al). The AASLD and IDSA guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Viekira Pak for 12 weeks is 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco and cortisone injection for treatment of the enrollees medical condition. Based on the documentation submitted for review, Norco and cortisone injection have not been established as medically necessary for treatment of the patients medical condition. In this case, the patient has a history of non-compliance with follow-up visits and imaging studies for treatment of his left shoulder. The patients providers have advised against continued opioid use and cortisone injections. In this clinical setting, the providers recommendation for treatment with anti-inflammatory medications is medically reasonable and appropriate. In addition, the patient should be re-evaluated by orthopedics to discuss treatment options prior to treatment with cortisone injections. As such, 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to himself or others. He had no self-harm urges.  He was medically stable.  He was no longer psychotic and he was not manic.  Although still depressed, this appeared to be at his baseline level.  There were no emotional, behavioral, cognitive or impulsive issues preventing him from continuing treatment at outpatient level of care. He was attending to his activities of daily living appropriately.  He had stable housing and family support.   He was actively involved in his treatment and future oriented. There was no evidence to suggest that continuing his treatment at a lower level of care would have led to decompensation.  His medication management could have been administered on an outpatient basis. The patient could have continued medication management, cognitive therapy, group therapy, and meetings in an outpatient program. The patient no longer required treatment at three days per week, multiple hours per day at IOP level of care.  In sum, the services at issue forward 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 is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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 coverage for ledipasvir-sofosbuvir (Harvoni) for treatment of the enrollees 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested ledipasvir-sofosbuvir (Harvoni) 90-400 mg for eight weeks is medically indicated for the treatment of this patient.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injections for treatment of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The use of epidural steroids for spinal stenosis has been shown to be not efficacious.  Randomized controlled trials have indicated that epidural steroids do not provide significant and sustained pain relief.  Further, this patient does not have signs of lumbar radiculopathy.  Her straight leg raising tests are negative bilaterally, and there is no sensory loss or loss of reflexes.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for pulse dye laser/V-beam laser treatment for treatment of the enrollees rosacea. Findings:  The physician reviewers found that the treatment of this patients rosacea with the pulse dye/V-beam laser is not supported by definitive evidence in the peer-reviewed medical literature. Traditional treatment for rosacea includes avoiding triggers and topical agents and antibiotics. There is a lack of data suggesting that the use of the pulse dye laser over traditional treatments with topical and oral medication and avoidance of triggering factors is likely to result in superior health outcomes. Final Result: Two of three reviewers determined that the services at issue were not and 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: Physician reviewers number one, two, and three are board certified in dermatology and 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 a consultation for Lap-Band surgery for evaluation of the enrollees obesity and sleep apnea. Findings:  The physician reviewer found that this patient is morbidly obese with a BMI of 39.26 kg/m2 on 4/11/16 and 40.4 kg/m2 on 4/20/16. According to the American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery, this patient is a potential candidate for definitive treatment with bariatric surgery.  Final Result: The reviewer determined that the requested consultation 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 surgery with sub-specialty certification in bariatric 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.