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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa injections for treatment of the enrollees osteoarthritis of the knees. Findings:  The physician reviewer found that evidence based medical peer reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis in their meta-analysis of 137 studies with 33,243 participants. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids. Colleagues conducted a systematic review of overlapping meta-analyses comparing intra-articular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis. They reported that the current highest level of evidence suggests that intra-articular hyaluronic acid is a viable option for knee osteoarthritis.  The American Medical Society for Sports Medicine (AMSSM) recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a very large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. This patient presents with left knee pain with associated effusion. She reported functional difficulty in walking and getting up from seated positions. Clinical examination findings are consistent with reported radiographic evidence of moderate left knee osteoarthritis. She had failed to improve with at least three months of NSAIDs and a recent corticosteroid injection. Therefore, the request for Euflexxa injections is medically necessary for 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 orthopedic 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal symptoms were mild-moderate, and did not require monitoring in the residential setting. The patient was not a danger to himself or others. There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care.  The patient was not agitated, psychotic or manic.  The patient was medically stable and he was psychiatrically stable. The medication changes and naltrexone management did not require 24 hours per day, seven days per week monitoring. The patient was cooperative, accepting the principles of treatment, and involving himself in his recovery.  The patient had a stable sober home environment with parents who are supportive. The medical literature supports that this patients relapse prevention and his development/solidification of coping skills can be achieved at partial hospitalization program level of care. Therefore, residential treatment center services from were not medically necessary for the 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 with sub-specialty certification in addiction 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 Lyrica for treatment of the enrollee, who has a history of diabetic polyneuropathy. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. Gabapentin is eliminated from the systemic circulation by renal excretion as unchanged drug. Gabapentin clearance is directly proportional to creatinine clearance, which is reduced in this case. The Health Plan requires that the patient try a higher dose of gabapentin prior to authorizing Lyrica, but his provider declines to do so because of the decreased creatinine clearance. The Health Plan requires him to try a tricyclic antidepressant for at least eight weeks. However, both tricyclic antidepressants have the major side effect of tachycardia. This patient has his heart rate controlled with beta blockers to treat his congestive heart failure, so a trial of a medication which is known to cause tachycardia is a poor choice.  The medical evidence supports Lyrica in this clinical setting. All told, the requested medication Lyrica 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for intensive outpatient program (IOP) services up to 60 days. Findings:  The physician reviewer found that the request for IOP services up to 60 days are not medically necessary for the treatment of the patients medical condition. The records provided for review show documented progress in almost all areas addressed in ABA therapy. The patients treatment of ABA therapy, services received through the school district, speech and physical therapy are medically appropriate to meet the patients medical needs without the implementation of further IOP treatment. In particular, the patient does not appear to require medical monitoring more than daily but less than weekly. In addition, there is a lack of medical literature supporting the efficacy of intervention with cognitive behavioral therapy (CBT) to address anxiety in a three-year-old child with autism. The medical literature supporting the benefits of CBT have been reported in older children, and children with high functioning autism. In addition, a recent report focused on decreasing anxiety in younger children aged four to eight with autism using ABA therapy techniques, which this patient is receiving. For the reasons provided, the requested services have not been established as 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 pediatrics and neurology with special qualification in child 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested authorization and coverage for genetic testing with clinical exome sequencing for evaluation of the enrollees progressive ataxia in legs and hands. Findings:  The 3 physician reviewers found that whole exome sequencing can be helpful in patients with symptoms of an underlying genetic disorder to diagnose them with a specific condition. The use of this method allows the patients providers to provide more effective therapy as well as genetic counseling for family members. This patient is likely to benefit from undergoing whole exome sequencing as she has a longstanding condition and would benefit from determining the cause of her symptoms. Given this support, the requested genetic testing with clinical exome sequencing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the requested testing 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification 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 authorization and coverage for Repatha Sureclick 140 mg/mL for treatment of the enrollees coronary heart disease. Findings:  The physician reviewer found the submitted documentation fails to demonstrate the medical necessity of the requested medication. The medical records document significantly increased coronary risk, but no symptoms or objective findings indicative of coronary vascular disease and no confirmed diagnosis of homozygous or heterozygous familial hyperlipidemia.  These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a family history of premature coronary disease (younger than 50 years in second-degree relative or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  The documentation does not support the patient meets criteria for this diagnosis.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient does not meet any of those criteria. PCSK9 inhibitors have not been studied in other patient populations, such as this patient. Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Therefore, the requested Repatha Sureclick 140 mg/mL  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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the blood test (advanced lipoprotein testing) for evaluation of the enrollees medical condition. Findings:  The 3 physician reviewers found that there is adequate evidence to support the benefits of early diagnosis and treatment of hypercholesterolemia. However, the role in advanced lipid panel testing including laboratory testing, which may provide a more comprehensive assessment of dyslipidemia and cardiovascular risk than standard lipid panel measurements, remains controversial. Although increasing levels of low density lipoprotein (LDL) cholesterol and non-high density lipoprotein (HDL) cholesterol are associated with an increased risk of atherosclerotic cardiovascular disease, there is little data to support the need for advanced lipid panel testing in the general population. Given this patients LDL cholesterol, aggressive therapy is indicated regardless of any potential results from advanced lipid panel testing. Thus, the blood test (advanced lipoprotein testing) was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 3 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 patient has requested authorization and coverage for Colestipol Hcl tablets. Findings:  The physician reviewer found that bile acid malabsorption diarrhea can occur in patients with Crohns disease who have had ileal resection. The use of Colestipol can be effective for the treatment of bile acid malabsorption diarrhea. The records indicate that this patient has failed Welchol and Imodium and has been successfully stabilized on Colestipol for many years. For these reasons, Colestipol Hcl tablets are supported as medically necessary for the treatment of this patients chronic diarrhea. Final result: The reviewer determined that the requested medication is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Synvisc One injection in the left knee. Findings:  The physician reviewer found that Hyaluronic acid injection for osteoarthritic knee pain received U.S. Food and Drug Administration (FDA) approval in 1996 and has become an established part of osteoarthritic knee pain treatment algorithms. Hyaluronic acid injections are generally considered a second-line treatment after exercise, weight loss and simple medications such as NSAIDs, or acetaminophen. Multiple studies have documented efficacy, although the magnitude of benefit varies between studies and individuals. In addition, NSAIDs, acetaminophen, opioids and oral or intra-articular corticosteroids can have systemic side effects and may not be reasonable treatment options for some patients. This patient has undergone gastric sleeve surgery, thus regular use of NSAIDs is not recommended. This patient has had good relief of symptoms with prior knee hyaluronic acid injection. For these reasons, the requested Synvisc One injection in the left knee is medically necessary for treatment of this patients knee pain. Final Result: The reviewer determined that the requested service 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 orthopedic 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 authorization and coverage for Zepatier for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Zepatier are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for individual speech therapy at 30 minutes per session, twice per week for treatment of the enrollees severe language delay. Findings:  The physician reviewer found that the U.S. Preventive Services Task Force support speech therapy as an effective treatment for children with speech language delays. The study by colleagues evaluated direct speech therapy versus indirect speech therapy and found that children with mixed receptive and expressive language delay required the skills of direct one-on-one speech therapy. Group speech therapy is recommended for children with autism to address pragmatic language and social problems. In this case, the patient needs to focus on articulation and basic language skills. These skills are effectively treated in an individual one-on-one setting. However, there is a lack of medical literature demonstrating that two speech therapy sessions per week are medically necessary in this clinical setting. As such, individual speech therapy at 30 minutes per session at the frequency of one session per week is clinically indicated for this patient. Based on the clinical documentation provided for review, individual speech therapy at 30 minutes per session, once per week is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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.