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

Nature of Statutory Criteria/Case Summary: A 60-year-old female enrollee has requested authorization and coverage for L4-5 and L5-S1 facet joint nerve (FJN) block. In the documentation available for review, the provider did not document examination findings consistent with facet arthropathy at all of the levels requested for treatment (case study). In addition, the patient is likely to obtain the same relief from a steroid injection alone without also having the increased risk from a radiofrequency ablation procedure (case study). All told, the medical records do not support the requested procedure in this clinical setting. Therefore, the requested authorization and coverage for L4-5 and L5-S1 facet joint nerve (FJN) block, 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for wireless capsule endoscopy. Findings:  The physician reviewers found that this patient has colonoscopy and biopsy findings suggestive of possible Crohns disease. Capsule endoscopy is useful for the diagnosis of Crohns disease or determination of the extent of disease activity, and superior to radiographic imaging tests such as small bowel follow through. Capsule endoscopy has been proven to be superior to all current forms of radiological testing of the small intestine in detecting the mucosal abnormalities of non-stricturing Crohns disease. Moreover, the test is supported by guidelines for the diagnosis of Crohns disease. For these reasons, requested wireless capsule endoscopy is likely to be more efficacious than the available standard therapy for the treatment of this patients medical condition.  Final Result: Two of the three reviewers determined that the requested wireless capsule endoscopy is 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:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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 authorization and coverage for transcatheter closure of patent foramen ovale (PFO). A series of studies recently confirmed the safety and efficacy of catheter based PFO closure in reducing the incidence of cryptogenic stroke. In the medical literature, among patients with a PFO who had had a cryptogenic stroke, the risk of subsequent ischemic stroke was lower among patients assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. Among patients who had a recent cryptogenic stroke attributed to PFO with an associated atrial septal aneurysm or large interatrial shunt, the rate of stroke recurrence was lower among those assigned to PFO closure combined with antiplatelet therapy than among those assigned to antiplatelet therapy alone. Among adults who had had a cryptogenic ischemic stroke, closure of a PFO was associated with a lower rate of recurrent ischemic strokes than medical therapy alone during extended follow-up. PFO closure is appropriate in patients with PFO and cryptogenic stroke and has been found to decrease the incidence of subsequent stroke. Thus, the requested transcatheter closure of PFO is supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the requested transcatheter closure of patent foramen ovale is 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:  One reviewer is board certified in surgery with sub-specialty certification in cardiothoracic surgery and is actively practicing. One Reviewer is board certified in surgery with sub-specialty certification in cardiothoracic surgery and is actively practicing.  One Reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular disease and is 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a seven-year-old male enrollee has requested reimbursement for psychiatric emergency medical services. The Health Plan has denied this request indicating the enrollee did not receive psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. According to the documentation submitted for review, the patient presented with a history of violent and aggressive episodes towards family, peers, and treatment providers. In the emergency room prior to inpatient admission, the patient required intramuscular chlorpromazine 25 mg due to escalating physical aggression. The patient displayed oppositional and aggressive behavior on the inpatient unit when the patient did not respond to redirection by staff. He was documented as engaging in aggressive behaviors including throwing, hitting, and kicking staff which required administration of chlorpromazine, as needed. Based on the patients clinical status, in addition to current medical literature, the inpatient level of care constituted emergency services for treatment of the patients behavioral health condition. For the reasons provided, the patient received psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the enrollee received psychiatric emergency medical services on the dates of service at issue. Therefore, the Health Plans denial should be overturned.  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 authorization and coverage for Vemlidy. Guidelines for the treatment of hepatitis B recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. The patient has already failed entecavir (Baraclude).  In comparison with tenofovir disoproxil fumarate (Viread), which the patient has been taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects, such as osteopenia and renal disease. The medical evidence supports the requested medication in this clinical setting. All told, Vemlidy is medically necessary 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 reimbursement for psychotherapy. The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity for the services at issue in this clinical setting. The guidelines provide no defined frequency or duration for the amount of psychotherapy required for each patient. However, it is generally accepted that patients in crisis require more frequent sessions than patients who are stable. The medical literature indicates that in unrestricted therapies, each additional psychotherapy session has a diminished effect. An article report that, at least in unrestricted therapies, the average rate of change during psychotherapy can be expected to diminish with each additional session irrespective of the length of treatment. These results are consistent with previous studies.  The documentation provided indicates the patient has had extensive psychotherapy with weekly sessions since 2013. Additionally, the documentation of the type of therapy performed during the dates in dispute is sparse and the type of therapy appears to be unstructured supportive psychotherapy.  In this case, there is a lack of support in the documentation provided as well as in the medical literature to support the medical necessity for the weekly psychotherapy sessions in dispute. Therefore, the patients psychotherapy services 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: The parent of a minor enrollee has requested authorization and coverage for an insulin pump. The Health Plan has denied this request indicating that the requested device is not medically necessary for treatment of the enrollees type I diabetes. Findings: The physician reviewer found that there is support in the documentation as well as in the medical records for the requested device in this clinical setting. This patient has a history of widely fluctuating blood glucose levels before meals, despite multiple dose adjustments and frequent blood glucose monitoring while receiving a multiple dose insulin injection regimen, which they have implemented since their initial diagnosis more than six months ago. Although their glycemic control is good, based on their recent HbA1c of 7.4%, they continue to have wide glycemic excursions and variations in their daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to treat their diabetes. Several studies published in peer reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents who are diagnosed with type I diabetes. The medical literature indicates that when compared to conventional insulin, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain, and reduces the frequency of hypoglycemic events. Accordingly, the results affect the overall satisfaction of patients and their parents. In addition, this patients care givers have demonstrated that they possess the necessary tools to carry out an effective treatment and follow up plan while this patient is on insulin pump therapy. Specifically, the patient and their family have adhered to frequent blood glucose monitoring, have kept appointments with the patients various health care providers, and have adhered to dietary recommendations. For these reasons, insulin pump therapy is medically necessary for treatment of this patients diabetes. Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in pediatric endocrinology 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: A 21-year-old female enrollee has requested reimbursement for the residential treatment center (RTC) services provided from October 4, 2017 through November 7, 2017. Applying the Level of Care Utilization System (LOCUS) criteria, the RTC services provided were not medically necessary. The patient presented with moderate risk of harm (score 3) as the patient does not have a history of suicidal ideation or prior suicide attempts. The patient demonstrated moderate functional impairment (score 3) with a significant deterioration in her ability to fulfill responsibilities. The patient has significant co-morbidity (score 3) with ongoing substance use despite negative consequences as well as a history of anxiety and depression. The patients recovery environment was moderately stressful (score 3) as the patient was recently homeless. The patient had a supportive environment (score 2) as her parents were supportive and willing to participate in family therapy. They were also willing for the patient to live in their home if the patient remains sober. The patients treatment history has resulted in equivocal results (score 3) as the patient was in an intensive outpatient program (IOP) and continued to use substances after this treatment. The patient was engaged and motivated in treatment (score 2) and the patient was compliant with medications. This evaluation gives the patient a composite score of 19 which is consistent with IOP level of care services. The patient would have also benefitted from a sober living environment. Thus, although the patient continued to require treatment for her opioid use disorder, this could have been accomplished at a less restrictive environment. Therefore, the RTC services provided were not medically necessary for treatment of this patients behavioral health issues. 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: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin. Nutropin AQ NuSpin is medically necessary for treatment of this patients medical condition.The submitted documentation supports the requested medication in this clinical setting. The age of two is the age at which GH therapy is recommended by the U.S. Food and Drug Administration for treatment of small, for gestational age, with failure to catch up.  However, GH therapy is medically necessary for this patient even though she does not meet the recommended age for GH therapy. The records demonstrate that this patient has extreme stunting of growth in association with Silver-Russell syndrome and would not likely catch up to the normal curve by two years old. Accordingly, the initiation of GH therapy at this point in time is supported by the clinical evidence. All other causes of poor growth, such as malabsorption and allergy, have been ruled out by other specialists. The benefits of treating patients who are diagnosed with Silver-Russell syndrome with GH have been shown to extend beyond improvement of stature growth. GH therapy in this patient population may also benefit with improved body composition, motor development, appetite, as well as a reduced risk of hypoglycemia. For the reasons noted above, Nutropin AQ NuSpin 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 Mavyret 100-40 mg tablets for 16 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that genotype 1a patients who have failed an NS5A inhibitor such as Harvoni should be re-treated with Mavyret for 16 weeks. These recommendations are based on the MAGELLAN-1 trial, which showed a 94% cure rate in this population.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100-40 mg tablets for 16 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: An enrollee has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.