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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure laboratory testing for evaluation of her premature labor. Three physician reviewers found that the testing was not likely to be more effective for this patient than any available standard therapies. According to the American Congress of Obstetricians and Gynecologists (ACOG) practice bulletin on premature rupture of membranes, AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. AmniSure is not recommended as a first-line test. One prospective study found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes and another study found it to be highly accurate in diagnosing fetal membrane rupture. However, per ACOG false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that this patient did not undergo standard testing prior to AmniSure testing, the testing at issue was not medically indicated or likely to be more beneficial for evaluation of the patients medical condition than standard testing. Final Result:  Three reviewers determined that the testing at issue was 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:  One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing. Two reviewers are board certified in obstetrics and gynecology 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 computer assisted navigation for total knee replacement (CPT code 20985) for treatment of her right knee osteoarthritis.  Three physician reviewers found that according to the referenced literature, computer assisted navigation with total knee replacement is beneficial in improving restoration of the joint line, decreasing perioperative blood loss, and improved functional outcome in those undergoing total knee arthroplasty. However, there is a lack of long term studies indicating longevity of functional outcome and prosthesis, and therefore, further studies are needed. As more studies are needed regarding the long term efficacy, the longevity of the prosthesis and functionality, computer assisted navigation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined 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 orthopedic surgery 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 a weeklong inpatient clinical evaluation including the attendant specialist consultations and tests for evaluation of her skin condition. The physician reviewer found that patients with Crohns disease not only experience symptoms arising from the inflamed bowel but may also be affected by certain extraintestinal manifestations at joints, skin or eyes. Mucocutaneous manifestations of Crohns disease encompass a broad array of clinical findings. These conditions can be challenging to treat, because the skin disease does not always mirror the Crohns disease course. The prevalence of pyoderma gangrenosum in patients with Crohns disease has been estimated to be 0.7% of patients. Clinically, the lesions appear first as erythematous pustules or nodules that progress to ulceronecrotic lesions with granulation tissue, pus, and rolled, violaceus, undermined borders, and are found classically as single or multiple distinct lesions in either a unilateral or a bilateral distributions. The pathergy phenomenon recognized in patients with pyoderma gangrenosum explains the occasional worsening of disease after biopsies or other site manipulations. This patients records document a complex medical problem that requires a thorough systemic work-up to avoid serious complications. The etiology of cutaneous ulceration may be related to her intestinal disease, which may also be the cause of her anemia. All told, the medical literature supports the requested weeklong inpatient clinical evaluation including the attendant specialist consultations and tests as medically necessary for evaluation and treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in dermatology 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 a denosumab injection for treatment of her osteoporosis.  Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Denosumab is U.S. Food and Drug Administration (FDA) approved for the treatment of postmenopausal osteoporosis in women at a high or increased risk of fracture. Studies have demonstrated that treatment with denosumab leads to a decrease in the frequency of both vertebral and non-vertebral fractures. Denosumab is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture or patients who have failed or are intolerant to other available osteoporosis therapy. This patient has experienced adverse reactions to bisphosphonate therapy in the past and she has taken Forteo for the maximum approved time period of two years. For the reasons provided, the services at issue were likely to be a more beneficial treatment than standard medical therapy in this clinical setting. Final Result: Two 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 reviewers are board certified in endocrinology and metabolism 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 a prenatal ultrasound for evaluation of her vaginal bleeding during pregnancy.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested prenatal ultrasound. While ultrasound evaluation in pregnancy is valuable, more than one ultrasound in the second and third trimester should be based on maternal or fetal complications. The practice guideline for the performance of obstetric ultrasound examinations recommends an obstetric sonogram in the second or third trimester that includes an evaluation of fetal presentation, amniotic fluid volume, cardiac activity, placental position, fetal biometry, and fetal number, plus an anatomic survey. The maternal cervix and adnexa should be examined as clinically appropriate when technically feasible. The medical literature further states The optimal timing for a single ultrasound examination in the absence of specific indications for a first-trimester examination is at 18-20 weeks of gestation. This patient had an ultrasound scan due to the patients recurrent vaginal bleeding, and another ultrasound was performed during an emergency department. This scan evaluated fetal growth, amniotic fluid volume and the placenta, but it did not re-evaluate fetal anatomy. As this patient has no risk factors for fetal anatomic abnormalities, another ultrasound for the purpose of fetal anatomic evaluation is not medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal 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 Harvoni for treatment of his hepatitis C virus (HCV).  Two physician reviewers found that 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 as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, the patient should be approved for Harvoni to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. He also suffers from cryoglobulinemia, which is an extrahepatic manifestation of HCV that is expected to resolve after the eradication of HCV infection. Therefore, treating this patient with Harvoni would prevent him from developing cryoglobulinemia-induced vasculitis and renal disease. Final Result:  Two reviewers determined 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis (CPT 77063) for evaluation of her medical condition.  Two physician reviewers found that although there is a lack of long term studies proving an increased survival rate when digital tomosynthesis has been added to mammographic images at screening, the addition of the technique has become the standard among providers due to a decrease in callbacks and increased rate of detection of small cancers. Thus, the addition of the technique is considered more beneficial to the patient than screening mammography alone. Final Result: Two 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: All three reviewers are board certified in diagnostic radiology 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 a power mobility device for treatment of the enrollee, who has been diagnosed with multiple sclerosis.  Findings:  The physician reviewer found that this patient has multiple sclerosis.  The records do not establish that the patient is unable to propel an optimally-fitted manual wheelchair.  Overall, the records do not demonstrate that the patients basic mobility-related activities of daily living could not be accomplished with a walker with a seat or a manual wheelchair.  Physical activity is generally encouraged for all persons, regardless of any underlying health conditions that may exist, including multiple sclerosis.  Exercise has been shown to improve fatigue, mobility and quality of life in the setting of multiple sclerosis.  The use of a walker or manual wheelchair would promote physical activity while accomplishing mobility-related activities of daily living.  All told, the requested power mobility device is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 24 weeks for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. 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. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. Cirrhotic genotype 1 patients who have failed prior therapy with peginterferon and ribavirin are recommended to be treated with Harvoni for 24 weeks. Thus, the requested treatment with Harvoni for 24 weeks is supported as medically necessary for treatment of this patients medical condition.  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:  The parent of an enrollee requested residential behavioral health treatment services for treatment of her post-traumatic stress disorder (PTSD), trichotillomania, and mood disorder.  Findings:  The physician reviewer found that the provided progress notes do not provide adequate documentation to support the medical necessity of 24-hour daily medical or nursing treatment for this patient. The psychiatric notes fail to indicate any concerns of dangerous behavior, such as thoughts of harming self or others, any psychosis, or significant impairment in ability to function. Specifically, these are issues commonly treated on an outpatient basis and do not require the services of a residential treatment center. Thus, the residential behavioral health treatment services in question were not and are not medically necessary for treatment of this patients medical condition. 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his hepatitis C virus.  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 Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. For patients with genotype 4 hepatitis C, AASLD/IDSA guidelines recommend daily Viekira Pak and weight-based ribavirin. This is based on the PEARL-I trial, in which treatment-naive non-cirrhotic patients with genotype 4 hepatitis C achieved sustained virologic response in 100% of patients after treatment. In addition, this regimen was well tolerated with no serious adverse events reported. Based on evidence of safety and efficacy in the published literature and clinical guidelines, treatment with Viekira Pak is medically necessary in this case. Final Result: Two 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested accessories for the power wheelchair, a Standing Seat (E2301) and the Power Seat Elevation System (E2300) for treatment of the enrollees quadriplegia.  The physician reviewer found that power standing is not of proven benefit with respect to health or functional outcomes in the setting of neurological or neuromuscular conditions resulting in standing or ambulatory dysfunction. Currently, there is a lack of high-grade evidence to support that this type of feature improves pulmonary function, circulation, bowel or bladder function, improves muscle function, skin integrity, bony health, or provides other health benefits in patients who are otherwise generally poorly mobile using their own body power. In addition, there is as yet no high-grade evidence to support that use of this type of device reduces osteoporosis or reduces fracture risk to a clinically significant degree in the setting of severe neurological disorders affecting the central nervous system or general health. The records indicate that this patient is at some elevated risk for pressure ulcers due to his condition, but the power standing feature would not be expected to significantly improve his overall risk profile for pressure ulcers. The power standing feature would potentially mitigate risk in some areas, but would also introduce new areas that would be at risk for pressure ulcer development. The patient does not have any documented respiratory impairments or other conditions that would be expected to be improved in any clinically appreciable or health-advantageous manner. The power standing feature is not medically necessary for the requested power wheelchair. With respect to the power seat elevation feature, the patient is already dependent for transfers. Power seat elevation would not increase his mobility or independence. For these reasons, the requested accessories for the power wheelchair, a Standing Seat (E2301) and the Power Seat Elevation System (E2300) are not medically necessary. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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.