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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested MiMedx amnion graft applications for treatment of her medical condition.  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient did not respond to accepted conservative tissue management.  Per the records, the patient experienced an excellent outcome, with a rapid response to treatment.  Alternative treatments for the patient included negative pressure therapy, hyperbaric oxygen therapy, progressive surgical debridement, specialty dressings, split thickness grafting and stem cell grafting.  In this case, there is support for the use of amniotic grafts.  All told, MiMedx amnion graft applications were likely to have been more effective than other treatment options.  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 podiatry 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 Botox injections for treatment of his moderate brow ptosis. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per the medical evidence, repeated Botox injections are not the standard treatment in this clinical setting.  The standard treatment for a visually significant brow ptosis is a brow lift surgery.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Botox 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 reviewer is board certified in ophthalmology 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 mastectomy gynecomastia, suction assisted lipectomy trunk (CPT 15877) for treatment of the enrollees gynecomastia.  The physician reviewer found that with regard to whether the suction assisted lipectomy trunk (CPT 15877) meets reconstructive surgery criteria, the patient presents with gynecomastia, an abnormal excess of male breast tissue. This is likely caused by developmental abnormalities that have not resolved with time. There is no evidence that liposuction would help to improve function or create a normal appearance to the extent possible. However, the requested mastectomy would likely contribute greater to an improvement in the patient's functional deficit of pain. In addition, liposuction does not offer more than a minimal improvement in the patients appearance as he has previously had significant liposuction and the remaining deficit is related to the sub-areolar tissue that should be directly excised. Therefore, the requested suction assisted lipectomy trunk (CPT 15877) does not meet the reconstructive surgery criteria. In sum, the requested mastectomy is medically necessary to correct a complication of a previously medically necessary surgery.  However, suction assisted lipectomy trunk (CPT 15877) is not medically necessary or reconstructive in nature for treatment of the patients gynecomastia. 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 partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of her medical condition.  Findings: The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested medication. The patient is requesting coverage for Otezla (apremilast) for treatment of psoriasis. The Health Plan indicates that for treatment of psoriasis with Otezla the patient must have a psoriasis area severity index (PASI) score more than 10, a failure or intolerance/contraindication to methotrexate, etanercept (Enbrel) and adalimumab (Humira). In this case, the patient has displayed intolerance/contraindication to the above medications. Therefore, in this case, the patients request for Otezla is medically necessary. 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  It appears that previous care was successful in breaking the cycle of substance use and capitalizing on the patients strengths.   Since the patient had no prior history of chemical dependency treatment in the outpatient setting, and considering the clinical presentation coupled with relevant peer-reviewed medical literature and current practice guidelines, there is no evidence to suggest that a less restrictive treatment setting would have been insufficient.  Thus, intensive outpatient program services were not and are not medically indicated for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a LifeVest wearable cardioverter defibrillator for treatment of her ventricular tachyarrhythmias. Findings:  The physician reviewer found that the patient presented with an out-of-hospital cardiac arrest due to ventricular fibrillation. The cause of the arrest is not clear. In this circumstance of a primary cardiac arrest due to ventricular fibrillation of uncertain cause, treatment with an implantable defibrillator is indicated and considered the standard of care in the medical community. The documentation provided for review does not provide a rationale for the delay an implantable defibrillator placement such as patient awaiting heart transplantation or an infectious process or other temporary condition that would preclude safe implantation of an implantable defibrillator at the time of discharge. For the reasons provided, the LifeVest wearable cardioverter defibrillator provided was not medically necessary in this clinical setting.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 internal medicine and cardiovascular disease 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 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that as per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The medical evidence supports Harvoni for eight weeks in this clinical setting given the patients viral load.  Specifically, Harvoni for eight weeks is appropriate for patients without cirrhosis with a viral load of less than 6,000,000 IU/mL.  However, Harvoni for 12 weeks is not medically indicated for the treatment of this patient. 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 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 a 12-week course of Harvoni for treatment of her hepatitis C.  Findings:  The physician reviewer found that the proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  The requested 12-week course of Harvoni is likely to prevent further damage of the liver and progression of the disease process and development of cirrhosis long-term and its potential complications.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, the requested 12-week course of Harvoni 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: The parent of an enrollee has requested GI effects comprehensive profile, immunoassay analyte complete gliadin sensitivity and food allergy panel total IgE and IgG. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is a lack of validated evidence indicating that the tests in question are more useful than standard testing in diagnosing any medical condition.  The actual utility of these tests, and their performance in comparison to the current gold standard celiac screening tools, has not been demonstrated.  Fecal calprotectin is a common and well accepted test for purposes of irritable bowel disease screening.  The additional testing in the panel tests for many elements of the stool microbiome whose health effects remain unknown, although they may be associated broadly with identified health conditions.  There is a lack of support for the services at issue in this clinical setting.  All told, the requested services are not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are 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 pediatrics with sub-specialty certification in pediatric 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 Harvoni for 12 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with virologic evidence of chronic hepatitis C infection, except for those with limited life expectancy of less than 12 months due to non-related conditions, should be considered for treatment. The proposed regimen of Harvoni for 12 weeks is recommended as a Class 1, Level A recommendation by the AASLD/IDSA. As such, the medical necessity for Harvoni for 12 weeks has been established in this clinical setting. 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 Harvoni for 12 weeks for treatment of his chronic hepatitis C virus 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, patients with cirrhosis are considered high priority for therapy. The patients ultrasound is accurate for diagnosis of cirrhosis. Per guidelines, treatment naive cirrhotic genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, 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. For these reasons, the requested treatment with Harvoni 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:   An enrollee has requested Viekira Pak for treatment of her hepatitis C virus. The physician reviewer found that according to the 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. Per the AASLD/IDSA guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials and is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested an intensive cardiac rehabilitation program for treatment of her myocardial infarction. Nature of Statutory Criteria/Case Summary:  Three physician reviewers found that based on the records provided, the patient presents with a non-ST segment myocardial infarction in the absence of obstructive coronary disease on angiography. In this circumstance of recent non-ST segment elevation myocardial infarction post discharge treatment guidelines have been developed, are periodically updated and are endorsed by several national organizations. These guidelines support use of traditional cardiac rehabilitation. All told, the guidelines do not suggest the requested intensive cardiac rehabilitation program is likely to be more beneficial than standard cardiac rehabilitation services for treatment of this patients medical condition status post myocardial infarction. Final Result: 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested air ambulance services for treatment of his end stage pulmonary disease. The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the services at issue. In this case, the patient presented to the hospital with progressive worsening dyspnea and chronic chough. The patient had rapidly deteriorating pulmonary function despite mechanical ventilation. The patients provider recommended the patient be emergently transported via air ambulance due to the need for a higher level care.  Minutes after arrival, the patient underwent ECMO cannulation.  The patients pulmonary dysfunction was an immediate threat to life and as such air ambulance transportation was medically necessary. For the reasons provided, air ambulance services was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 general surgery and critical care 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 assistant surgeon services during breast reconstruction surgery for treatment of her breast deformity status post bilateral mastectomy and reconstruction.   The physician reviewers found that this patient underwent breast reconstruction revision with replacement of a tissue expander with permanent prosthesis, removal of an intact mammary implant and revision of a reconstructed breast. In the medical literature, Slezak noted that complication can occur with breast reconstruction that requires varying degrees of revision. While an assistant surgeon may be indicated for complex primary breast reconstruction and possibly for revision, the level of difficulty of this surgical revision/reconstruction has not been established, as the operative report has not been provided. As such, the available medical documentation does not support the medical necessity for the assistant surgeon services provided during breast reconstruction surgery.   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 plastic 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.