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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior efficacy of the services at issue.  The genetic testing will not alter the clinical course of this patient.  She has known antithrombin deficiency and will need lifetime anticoagulation.  She can be switched to an alternate medication to avoid the complications of her current medication, and genetic testing does not alter this decision.  All told, genetic testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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: All three reviewers are board certified in internal medicine 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:  The parent of an enrollee has requested Copaxone 40 mg for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Copaxone daily has resulted in pain and injection site lumps that make rotation of sites difficult.  Her provider has recommended Copaxone 40 mg, three times weekly.  Patient adherence can be impacted by side effects, such as pain and injection site reactions.  Overall, three times weekly injections are likely to be less irritating and foster adherence.  Copaxone 40 mg, three times weekly has been shown to have comparable tolerability and effectiveness as 20 mg daily.  Given the potential for optimized adherence, Copaxone 40 mg 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 neurology 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 mandibular advancement device for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. This patient does not have clinically significant obstructive sleep apnea, and there is no indication for treatment of obstructive sleep apnea.  The usual criteria to treat obstructive sleep apnea in the absence of hypertension, cerebrovascular accident or heart disease, is an AHI of 15 or higher.  The patient does not meet this criteria.  All told, the requested mandibular advancement device is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 pulmonary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested  gamma skin graft for treatment of his medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The medical documentation does not support that non-biologic therapies were used as first-line wound care prior to surgical application of the allograft.  Per the medical evidence, skin allograft is not a first-line wound care technique.  Local wound care with hydrocolloids, closure by secondary intention and blood glucose control is tantamount to good wound closure.  In sum, gamma skin graft was not likely to have been of greater benefit than other treatment options.  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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BRCA gene testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the submitted documentation does not support the requested services in this clinical setting.  BRCA gene testing is premature in this patient. There is no mention of siblings or ethnicity, both of which may impact the pre-test probability of this patient being a BRCA carrier.  Thus, the requested BRCA gene testing is not likely to be more effective than other modalities for evaluating this patient. Final Result: Two reviewers determined that the requested services are 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 partial hospitalization program services for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Initially, the patient had neither demonstrated the ability to maintain weight nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  Thus, discharge at that time would have been consistent with inadequate care.  Thereafter, the patient continued to engage in active treatment services.  The patient was both psychiatrically and medically stable, and he was future oriented.  This patients anorexia nervosa necessitated comprehensive specialty care, and the partial hospitalization services were safe, appropriate and consistent with good medical practice initially.  However, based on the patients progress and clinical stability despite the chronicity of the illness, the records did not suggest that partial hospitalization would further improve the patients condition and/or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting.  All told, partial hospitalization program services provided initially were medically necessary, but not thereafter. 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 partially overturned.  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 residential level of care services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue.  The medical records failed to demonstrate that less restrictive interventions targeting her substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  Considering the patients clinical presentation and treatment history, there is a lack of evidence suggesting that comprehensive specialty services provided at a lower level of care, such as partial hospitalization or intensive outpatient programming with therapeutic inclusion of marital counseling and community-based peer support and sponsorship, would have been unreasonable or consistent with inadequate care.  Thus, residential treatment center services were not medically necessary 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a cooling device for approximately 4 weeks for treatment of his medical condition.  Findings:  Two physician reviewers found that the cooling device at issue provides compression and localized cold thermal therapy.  Indications include edema reduction, lymphedema, and chronic venous or arterial insufficiency. Cold compression/continuous-flow cryotherapy is recommended as an option after knee surgery. In the post-operative setting, continuous flow cryotherapy units have been proven to decrease pain, inflammation, swelling, and narcotic usage. However, post-operative use of up to seven days is generally recommended. In this case, the unit was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that a portion of the equipment at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pain management and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation 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 treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per 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 should be treated except those with limited life expectancy due to non-liver-related conditions. According to the guidelines, patients with cirrhosis are considered highest priority for treatment. In patients with decompensated cirrhosis, guidelines recommend treatment with Harvoni with ribavirin for 12 weeks. The only alternatives are Sovaldi/Daklinza/ribavirin and Sovaldi/Daklinza (in ribavirin-intolerant patients). The Harvoni recommendation is based on the SOLAR-2 trial, which demonstrated efficacy in this population. The AASLD/IDSA guidelines specifically recommend against treatment of decompensated patients with Viekira Pak in a Red Box warning, and the United States Food and Drug Administration has warned that Viekira Pak can induce serious liver injury in patients with advanced liver disease.  For these reasons, the requested treatment with Harvoni (to be used with ribavirin) 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 Opana ER for treatment of her medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has a chronic pain diagnosis, which has been treated with a number of modalities, and multiple narcotic and non-narcotic pain medications. Researchers report that for chronic non-cancer pain, short and long acting opioid has been found to be effective. The authors also suggested that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In this case, the patient has failed treatment with some medications, and could not tolerate some others. The patients provider has also recommended non-pharmacological therapies. However, given the patients uncontrolled pain, she will not likely be able to perform the recommended therapies. In this clinical setting, a trial of Opana ER is medically necessary to allow the provider to document patient outcome in terms of improvement of function and possible decrease in short-acting narcotic use.  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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure testing for evaluation of her medical condition. Findings:  Three physician reviewers found that the diagnosis of ruptured membranes can generally be made on the basis of clinical examination and nitrazine and fern testing.  There have been false positive results from AmniSure.  In this patients case, the records do not document that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning.   It does not appear that these standard evaluations were performed.  The routine use of AmniSure to diagnose ruptured membranes is not recommended.  Thus, AmniSure testing was not likely to have been more efficacious than other methods of evaluating this patient. Final Result: Three reviewers determined that the services at issue were 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:   All three 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patients prior treatment has included physical therapy.  However, details regarding the duration of physical therapy and documentation of a home exercise program were not provided.  The current medical evidence supports active exercise with the physical therapy in this clinical setting.  The medical literature indicates that a home exercise program after physical therapy independent of an epidural may provide lasting results. Additionally, the patient does not have any recent physical examination findings supporting a diagnosis of lumbar radiculopathy.  Per the records, magnetic resonance imaging (MRI) scan did not show evidence of nerve root compromise.  There are other tests that could be done to demonstrate a nerve problem which have not been performed.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. 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. The guidelines indicate patients with diabetes are high priority for therapy. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C 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 the AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. 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. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni 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 gastroneterology 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.