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

Nature of Statutory Criteria/Case Summary:  An enrollee requested a panniculectomy for treatment of her overlapping abdominal pannus.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery.  The patients functional issues have been noted to have been present for several months. The patient has failed conservative management of antibiotic treatment and local surgery for cyst removal. The overhanging pannus is likely contributing to the chronic open wound and history of infected cyst. Therefore, a panniculectomy would likely address this functional deficit and is medically necessary for treatment of the patients medical condition.  With regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with a severely overlapping abdominal pannus with apparent active intertrigo. The patients chronic wounds may be associated with infection in which the severe pannus is a likely contributing factor. The requested surgery is being performed to improve function. The patient has had multiple chronic conditions associated with her severely overlapping abdominal pannus and has failed reasonable conservative management of wound care, local surgical correction of a chronically infected cyst and medical management. The requested panniculectomy would likely address the functional deficit. Although the requested panniculectomy would offer a significant improvement in the appearance of the patient, this is not the primary goal. The patient has a functional deficit related to the severe pannus. The submitted documentation shows that this patient has a severely overlapping abdominal pannus that is likely significantly contributing to her functional deficit of poor healing and chronic infection. Therefore, the requested surgery does meet the reconstructive surgery criteria.  Final Result: The reviewer determined that the requested surgery is medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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 Harvoni for eight weeks for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. However, the published literature and AASLD/IDSA guidelines do not support Harvoni over Viekira Pak in this case. Thus, the requested Harvoni for eight weeks is not supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: Two reviewers 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 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 Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Three physician reviewers 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 HCV regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation per AASLD/IDSA. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug (FDA) approved for all patients with chronic HCV genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni for 12 weeks should be considered medically necessary in this case.  Final Result:  Three reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers 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 HCV, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Per AASLD/IDSA, patients without cirrhosis who have failed prior therapy with interferon regimens are recommended to be re-treated with Harvoni for 12 weeks. In the ION-2 trial, non-cirrhotic patients who had failed peginterferon regimens demonstrated 94% sustained virologic response with Harvoni.  Treatment with Harvoni for eight weeks is not supported by clinical guidelines in this clinical setting. As such, the medical necessity for treatment with Harvoni for eight weeks has not been established. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Tylenol with codeine for treatment of her chronic pain and headaches. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Tylenol with codeine has not been established. According to Argoff and Silvershein Management of chronic noncancer pain (CNCP) requires a comprehensive assessment of the patient, the institution of a structured treatment regimen, an ongoing reassessment of the painful condition and its response to therapy, and a continual appraisal of the patient's adherence to treatment. In this case, the patient presents with liver disease, chronic pain and migraines with multiple drug screens showing the patient tested positive for marijuana. According to Weatherall, Many patients with chronic migraine also have medication overuse, defined as using a compound analgesic, opioid, triptan or ergot derivative on at least 10 days per month. Given the patients liver disease and positive drug screens the requested Tylenol with codeine is not medically necessary in this clinical setting. 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 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 tramadol for treatment of the enrollees restless leg syndrome.  The physician reviewer found that based on the available medical literature, the use of tramadol is not considered the standard of care to manage this patients medical condition. Further, there is a lack of controlled studies supporting the safety and efficacy of the long-term use of tramadol for restless leg syndrome. As noted by Zhang and colleagues, long-term studies and more evidence of head-to-head comparisons of pramipexole with other dopamine agonists, anticonvulsants, and levodopa are needed. All told, the requested tramadol is not supported as medically necessary for treatment of this patients restless leg syndrome. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in neurology with sub-specialty certification in neuromuscular 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 a referral to a neurogastroenterologist for treatment of his chronic gastrointestinal (GI) issues.  Findings:  The physician reviewer found that the records document that this patient has experienced worsening constipation and incomplete defecation. Anatomic and functional reasons for his symptoms need to be evaluated. For diagnosis, he will need specialized evaluation and may need referral for testing such as defecography or balloon expulsion test. Neurogastroenterology is the medical specialty that diagnoses and treats patients with disorders of gastrointestinal motility and gastrointestinal function, including irritable bowel syndrome, which is one possible cause for the patients symptoms. Given that the patient has been evaluated by a number of gastroenterologists without a diagnosis or effective treatment, referral to a specialist in neurogastroenterology is warranted. Accordingly, the requested referral to a neurogastroenterologist for evaluation and treatment of his functional bowel syndrome is supported as medically necessary. Final Result: The reviewer determined that the requested referral 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 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 Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the national American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines give both Harvoni and Viekira Pak (with or without ribavirin) the same class recommendation, which implies that both are equivalent. In addition, both Viekira Pak (with or without ribavirin) and Harvoni have the same efficacy and relatively low and mostly minor adverse side effects. There is a lack of evidence in the documentation submitted for review showing that this patient has a contraindication to ribavirin. Therefore, although this patient should be treated for chronic HCV, there is a lack of data demonstrating the patient has a contraindication with Viekira Pak which has been authorized by the Health Plan. As such, the requested medication is not medically necessary in this clinical setting. Final Result: Two reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested serum infliximab tests (Prometheus Anser IFX tests) for evaluation of his Crohns disease.  Three physician reviewers found that in the management of this patient, therapy should be guided by response. Thus, if the patient is failing infliximab at 5 mg/kg every eight weeks then empiric escalation to 10 mg/kg is usually advised. Once at this threshold, continued symptoms would support switching to another agent. However, failure can be due to other causes which also need to be ruled out with a pouch exam including biopsies. Currently, there is a lack of an established role for serially following infliximab levels in this clinical setting to guide treatment decisions. Accordingly, the serum infliximab tests (Prometheus Anser IFX tests) were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment level of care services for treatment of the enrollees depressive disorder and polysubstance dependence.  The physician reviewer found that although episodic treatment is often necessary for patients afflicted with psychotic illness and substance use disorders, the services provided                                                                                                                                                                                                                                                                                                                             were not medically necessary for treatment of this patients medical condition. There was no psychiatric evaluation, psychosocial assessment, history and physical, treatment plan or integrated summary justifying the necessity of the placement. The progress notes that were provided did not describe behaviors, symptoms, or treatment interventions that require a 24-hour medically-supervised setting. The patient was anxious. Her bupropion was discontinued for concern that its noradrenergic effects were exacerbating her anxiety. She had limited insight and mild to moderate paranoia, but neither negatively impacted her thought processing, which was described as coherent, linear, and goal-directed. Further, the patient was not depressed, psychotic, delusional, suicidal or homicidal. There was no mention of symptoms or sequelae from her amphetamine dependence. Subsequently, the patients mental status examination was identical while she was actively engaged in her treatment and noted to be eating and sleeping well. The provider recommended cross-tapering the patients antipsychotic medication from risperidone to lurasidone due to concerns of weight gain and fatigue. However, this type of modification can be safely performed in less restrictive settings. In sum, the services provided at the residential level of care were not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  In this case, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Three reviewers 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential level of care services for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  In this case, substance use was prominent.  However, the record did not demonstrate that the patient had failed less restrictive levels of care, non-pharmacological interventions, community programming, family counseling or evidence-based psychotherapies and pharmacological strategies targeting his addictive illness during the episode of illness, as it appears that he concluded monthly therapy.  Further, the patient had no psychiatric or medical comorbidity.  He had an unremarkable physical examination and stable vital signs upon presentation.  The psychosocial assessment noted his motivation for recovery and strong support system.  This patients symptom complex was not consistent with a severity that would require treatment in a 24-hour supervised setting.  Additionally, there was no discharge summary, treatment plan or explanation opined by the treatment team articulating the necessity of the residential setting as opposed to well-organized, evidence-based substance use interventions delivered in a less restrictive setting.  In the absence of such clinical documentation, there is no evidence to suggest that a lower level of care would have been insufficient.  All told, residential level of care services were not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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.