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 scleral contact lenses. Findings:  The physician reviewer found that the records provided for review document two reasons for this patient to wear contacts. First, contact lenses are necessary for the anisometropia and the patient will be unable to wear glasses given the significant difference in the prescription between the two eyes. Second, the patient has dry eyes for which scleral contact lenses are the best choice. Studies concluded that Scleral lenses are efficacious and well tolerated for use in severe dry eye syndrome. Given these findings, the use of scleral contact lenses in this patient is medically necessary. Final Result: The reviewer determined that the requested equipment 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Armour thyroid for treatment of the enrollees hypothyroidism.Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting. The treatment of choice for correction of hypothyroidism is synthetic thyroxine. The American Thyroid Association/American Association of Clinical Endocrinologists do not recommend the use of desiccated thyroid as replacement therapy for hypothyroidism.  In this case, the patient is requesting the use of Armour thyroid (desiccated thyroid) for the treatment of her condition of hypothyroidism.  There is no evidence that she has tried or had an adverse outcome to the synthetic thyroid medication, which is first line treatment.  Final Result: The reviewers 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 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 of Harvoni. Findings:  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 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. For treatment naive patients with genotype 6, hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. AASLD guidelines cite data showing reduced survival with delayed 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Norco 10 mg. Findings:  The physician reviewer found that the stepwise World Health Organization ladder for pain relief is considered the reasonable approach to pain control in the palliative and the non-palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function were noted for the requested medication. The Centers for Disease Control and Prevention (CDC) states that when starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids. The CDC also states when opioids are started, clinicians should prescribe the lowest effective dosage. The CDC states regarding co-prescription of opioids with benzodiazepines, epidemiologic studies suggest that concurrent use of benzodiazepines and opioids might put patients at greater risk for potentially fatal overdose. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. There is a lack of medical evidence based rationale given for the increase in Norco by this patients provider or by the patient. There is a lack of evidence regarding the long term consequences with the continual increase of this medication. The records indicate that tolerance has taken place since the start of the narcotics. There has been no difference in pain scores or objective function despite the increase in the amount of opioid medication he is taking. Moreover, there has been no documented improvement with the current amount of Norco. There are no clear objective goals for the higher dose of opioid. Increases in the past appear to have been done only on the basis of pain levels, which is especially concerning since not all other non-pharmacological ways of taking care of the pain have been done. There is no mention of completion of behavior therapy documented despite much research to support its use. Finally, not all non-opioid medication classes have been optimized or tried. For all these reasons, the requested coverage for Norco 10 mg is not medically necessary for treatment of the patients  medical condition. 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 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 reimbursement for treatment of rib fracture. Findings:  Three physician reviewers found that this patient has multiple indications for the surgery that was performed. He reported chronic pain from the displaced ribs at multiple levels. The records indicate the severity of the displacement, ranging from 2 to 4 cm overlap between the ribs, anteriorly and posteriorly. Additionally, there was instability of the chest wall noted. The scissoring effect of the overlapped ribs impinged on the intercostal nerves located immediately beneath each rib, leading to his severe chronic pain related to the unstable chest wall fractures. The records demonstrate that surgery was indicated for this patient. The efficacy of rib stabilization by plating has been shown in prior studies. The medical literature has also shown the superiority of this procedure over conservative medical management. For these reasons, treatment of rib fracture received was likely to have been superior to other alternatives for treatment of this patients medical condition. Final Result: 3 of 3 reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in thoracic and cardiac surgery and are actively practicing. The 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 reimbursement for computed tomography (CT) scan of the thorax and abdomen/pelvis. Findings:  The physician reviewer found that the submitted documentation as well as the National Comprehensive Cancer (NCCN) guidelines demonstrate the medical necessity for the services at issue. According to NCCN guidelines, the conduction of CT scans at the two year mark conform to guidelines for this lymphoma.  The presence of the enlarging nodes noted in the pelvis caused the provider to plan a closer surveillance with CT. There was some concern of recurrence and the plan was to follow her with CT of the abdomen and pelvis four months later.  The decision by the provider to utilize CT scan adhered to the NCCN guidelines and standard practice. For these reasons, CT scan of the thorax and abdomen/pelvis provided for the evaluation of this patients medical condition was medically necessary. Final Result: The reviewer determined that the service at issue was 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 diagnostic radiology 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 reimbursement for MyRisk gene panel testing. Findings:  Two physician reviewers found that the patients family history is suggestive of a breast/ovarian cancer syndrome. BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers. BRCA2 mutations can increase risk for breast, ovarian, gall bladder, bile duct, prostate, pancreatic, and gastric cancers. In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect. The Amsterdam criteria and the Bethesda consensus guidelines evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families. The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral. In this clinical setting, the MyRisk gene panel testing provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Reviewers 2 and 3 determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The 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 requested authorization and coverage for general dental anesthesia. Findings:  The physician reviewer found that in this patients case, the record demonstrates that she had multiple cavities but the provider could not treat her because the patient was uncooperative. Further documentation indicated that that communication techniques had failed. The patient requires extensive dental work. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. 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 anesthesiology 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 a computed tomography (CT) scan of the left foot. Findings:  The physician reviewer found that the gold standard in the diagnosis of gout is demonstrating uric acid crystals in the joint fluid or in tophi. Bony alterations occur only years into the illness and even then, only 45% of patients have radiographic findings. Further confusing the issue is that hyperuricemia can occur in patients who do not have gout. Early diagnosis is important, as uric acid lowering medications can play a role in preventing functional impairment. Over the years, various modalities have been developed to more accurately diagnose gout Historically, radiographs have been the mainstay of imaging, but only demonstrate chronic (irreversible) changes.  More recently, CT, magnetic resonance imaging (MRI), and ultrasound have been used. CT is the best modality to demonstrate bony changes, while MRI is better for soft tissues. Ultrasound has some advantages as well, but is highly operator dependent and has a small field of view. Dual energy CT scanning has shown to be promising in differentiating the various crystals. While there are some problems with specificity, at the very least, if one can diagnose crystalline disease, one can exclude simple osteoarthritis.  Final Result: The reviewers determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: the physician reviewer is board certified in diagnostic radiology 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 authorization and coverage for Combigan 0.2% - 0.5% drops. Findings:  The physician reviewer found that Combigan is a combination of timolol 0.5% and brimonidine 0.2%. The main advantage of the using combination drop is the convenience since the same IOP lowering effect can be achieved with using the same medication (timolol and brimonidine) as single agents. The standard practice would be to prescribe timolol and brimonidine as separate drops. Alternatively, there are other combination drops that are covered by the Health Plan (Cosopt or Simbrinza) which could also be used instead with similar efficacy. The documentation provided did not indicate an intolerance to the drops that are covered by the Health Plan. Final Result: Two of the three physician reviewers determined that the requested medication is 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 physician reviewers are board certified in ophthalmology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and are 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 intravenous (IV) magnesium via home IV infusion. Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Magnesium is primarily absorbed from the gastrointestinal tract, and diarrhea can result in magnesium losses.  Low magnesium level can result in multiple symptoms consistent with this patients presentations, and can also cause cardiac arrhythmias, so treatment of hypomagnesemia is necessary.  The patient has had severe gastrointestinal side effects with oral magnesium. However, the medical literature indicate that intravenous magnesium can result in larger and more rapid increases in magnesium levels than oral magnesium. Additionally, hypomagnesemia and hypermagnesemia present with similar symptoms, so rapid laboratory testing of magnesium level may be needed during infusion to determine the actual magnesium level.  Excess magnesium can be associated with hypotension, drowsiness, muscle weakness, respiratory depression, cardiac arrhythmia, coma, and death.  The cardiac abnormalities are manifold which may include bradycardia, complete heart block, atrial fibrillation, and asystole (cardiac arrest). As such, monitoring and administration in a setting in which emergency treatment can be provided is advisable. Moreover, the prescribing information approved by the U.S. Food and Drug Administration, magnesium overdose is manifested by a sharp drop in blood pressure and respiratory paralysis, and artificial ventilation must be provided until a calcium salt can be injected IV to antagonize the effects of magnesium (Package insert). 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 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: a parent of an enrollee has requested authorization and coverage for 40 hours per week of direct applied behavioral analysis (ABA) therapy, eight hours per month of supervision and six hours per month of parent training. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has problematic behaviors which include tantrums, aggression, and vocal scripting. The patient has difficulty matching pictures with objects and requires a significant amount of modeling and direction at school. Failure to master these skills puts the patient at an increased risk for injury, and makes it difficult to be successful in more generalized environments. The Behavior Analyst Certification Board states that typical comprehensive ABA programs range from 30 to 40 hours of treatment per week. Final Result: The reviewer determined that the requested services at issue 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 pediatrics with sub-specialty certification in developmental-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.
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 25 mg oral tablets, daily for six months. Findings:  The physician reviewer found that guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), which the patient is 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. 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested reimbursement for the gene test performed. Findings:  The physician reviewer found that  the American Thyroid Associations guidelines state that for nodules with FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. If genetic testing is suspicious, the risk of malignancy increases to 40 percent. In this case, the result of the Afirma GEC was suspicious for malignancy. This information was important to determine the decision whether to perform thyroidectomy and the extent of surgery. There are multiple peer-reviewed scientific articles indicating the benefits of the genetic test in thyroid nodules. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: the physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and is actively practicing. The 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.