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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility (SNF) inpatient stay for treatment of the enrollees transverse myelitis secondary to lupus or antiphospholipid syndrome, and recent perforation of the rectum status post partial colectomy. The physician reviewer found that the patients request for SNF inpatient stay because of paralysis from transverse myelitis secondary to lupus was and is medically necessary. Her current functional status is significantly lower than her baseline. Studies have shown that recovery from transverse myelitis is seen during months three to six after symptom onset and may continue for up to two years and recovery may be rapid during months three to six after symptom onset. As such, the patient will continue to benefit from more intensive rehabilitative therapy in a SNF because she is within the window of time when recovery from transverse myelitis is expected. Many patients with transverse myelitis will require rehabilitative care to prevent secondary complications of immobility and improve their functional status. Studies suggest daily land and/or water based therapy for 8 to 12 weeks, and weight bearing exercises for 45 to 90 minutes daily in both early and late stages of rehabilitation. The patients requested SNF inpatient stay will allow her to continue suggested daily therapy and exercises for functional recovery, this would be difficult to achieve with home health therapy. Moreover, functional recovery in transverse myelitis patients with lupus may occur later in the disease process. Thus, the SNF services are supported as medically necessary. Final Result: The reviewer determined that the services at issue were and 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 internal medicine with sub-specialty certification in geriatric 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:  An enrollee has requested laboratory testing to screen for cancer for evaluation of the enrollee, who has a history of squamous cell carcinoma of the skin. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of squamous cell carcinoma of the chest which was treated with wide local excision and completely removed.  He is requesting further testing to ensure that there is no remaining cancer in his body, given a personal history and family history of malignancy.  The patient was referred to a dermatologist for a full skin examination, and the records documented no evidence of recurrence, nodularity or issues with healing at the surgical site.  No other suspicious lesions were identified.  Given that the patient was treated with wide local excision and the pathology revealed clear margins and complete removal of the skin cancer, he has received the appropriate medical treatment and standard of care for this diagnosis.  There is no mention of perineural invasion of this tumor or other suggestions that would make it a high risk tumor.  Therefore, the appropriate follow-up therapy is sun protection and routine full skin examinations.  All told, the requested laboratory testing to screen for cancer is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C.  Two physician reviewers found that 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 hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for Harvoni in this clinical setting.  In this patients case, Harvoni is medically indicated to prevent further progression of fibrosis due to hepatitis C infection and prevent potential complications of advanced liver disease in the long-term.  All told, Harvoni is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Viekira Pak for treatment of her hepatitis C.  Two physician reviewers found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except patients with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The current medical evidence supports Viekira Pak for treatment-naive patients.  Based on evidence of safety and efficacy in the published literature, the requested Viekira Pak is medically indicated for the treatment of this patient.  Final Result:  Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 magnetic resonance imaging (MRI) of the brain stem without dye for evaluation of his medical condition.  The physician reviewer found that the patient has had obstructive sleep apnea, treated with improvements in apnea, but with continued reduced sleep efficiency.  The medical records document continued fatigue.  However, the documentation does not indicate that medical causes of fatigue, such as anemia, hypernatremia or hypothyroidism, have been evaluated.  The medical literature indicates a greater chance of dementia and stroke in patients with sleep apnea.  Additionally, there is an association with central apnea and brain pathology, but no particular causal relationship is cited to indicate that obstructive sleep apnea is caused by brain pathology.  No neurologic examination was provided to suggest focal clinical signs, for which there would be reasonable expectation of brain pathology.  Thus, the requested MRI of the brain stem is not likely to lead to changes in treatment and is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested diagnostic procedure is 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 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 facial feminization surgery (mandibular segmental osteotomy and genioplasty) for treatment of her gender identity disorder. The physician reviewer found that according to the World Professional Association for Transgender Health (WPATH) Standards of Care, While most professionals agree that genital surgery and mastectomy cannot be considered purely cosmetic, opinions diverge as to what degree other surgical procedures (e.g., breast augmentation, facial feminization surgery) can be considered purely reconstructive. A study by Capitan and colleagues found that the modification and elimination of masculine facial features allows patients to adapt more easily to the workplace and social and family environments. Upon review of the submitted clinical documentation including photographic images, the patients lower jaw and chin are not overtly masculine and are within the range of normal for a female. The photographs document a normal mandible that does not show retrognathia or prognathia. The mandible has acceptable chin position and the mandible is not excessively wide. The mandible shape is considered within normal size for a female. The proposed surgery may change the mandible and lower facial shape but the changes are not specific for gender and are considered cosmetic in nature. As such, the requested services are not medically necessary for the treatment of gender dysphoria. With regard to the reconstructive surgery criteria, the patients current facial features do not represent an abnormal structure of the body. The patients lower jaw and chin are within the range of normal for a female. Therefore, the requested services are not considered reconstructive in nature. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or reconstructive in nature. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys spray for treatment of his malignant neoplasm of larynx and chronic pain syndrome.  The physician review found that according to the National Comprehensive Cancer Network (NCCN), rapidly acting transmucosal fentanyl may be considered in patients who are opioid-dependent and have brief episodes of pain that is not effectively controlled or attributed to inadequate dosing of around-the-clock opioids medications. The NCCN guidelines also indicate that transmucosal fentanyl is often the choice for patients who are unable to swallow. Additionally, the U.S. Food and Drug Administration (FDA) states that Subsys is indicated for the management of breakthrough pain in adults with cancer, who are already routinely taking other opioid pain medicines around-the-clock for cancer pain. The documentation provided for review indicates that the patient has been diagnosed with metastatic nasopharyngeal carcinoma of the neck that is associated with severe neck pain and swallowing difficulties. The patient is currently prescribed oxycodone and Vicodin for management of the cancer pain which was noted to adequate control the pain. However, the documentation also indicates that the patient has continued complaints of unpredictable episodes of breakthrough pain. Overall, the medical literature supports the use of Subsys in this clinical setting for this patients breakthrough cancer pain despite treatment with 24-hour opioid medications. Therefore, based on the referenced medical literature, the requested Subsys spray 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 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 bilateral radiofrequency facet denervation of the sacroiliac joints for treatment of her chronic back pain. The physician reviewer found that the submitted documentation establishes the medical necessity for the requested services. According to the documentation submitted for review, this patient presents with SI joint pain and has had positive results with previous radiofrequency ablation of the SI joint. Additionally, there is medical literature supporting the utility of SI joint rhizotomy for pain due to sacroilitis. Ferrante and colleagues reported on the results of a consecutive series of 50 SI joint radiofrequency denervations performed in 33 patients with sacroiliac joint syndrome. The results of the study suggested that radiofrequency denervation of the SI joint can significantly reduce pain in selected patients with sacroiliac syndrome for a protracted period. Moreover, Yin and colleagues performed a retrospective audit to determine the effectiveness of sensory stimulation-guided radiofrequency neurotomy for the treatment of recalcitrant sacroiliac joint pain. The authors concluded that a sensory stimulation-guided approach toward the identification and subsequent radiofrequency thermocoagulation of symptomatic sacral lateral branch nerves appears to offer significant therapeutic advantages over existing therapies for the treatment of chronic sacroiliac joint complex pain. Based on the clinical documentation submitted for review and peer reviewed literature, the medical necessity of the requested services has been established in this clinical setting. 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dental services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention. In this case, the patient presented with luxation of the anterior teeth, alveolar fracture, and pulpal necrosis. A failure to stabilize these conditions would reasonably be expected to cause serious dysfunction of a body part, the anterior dentition. The pulpal necrosis treatment is an integral part of stabilization of the patients acute injury. The review by Ritwick found that there was an association between pulp extirpation performed within 10 to 14 days after tooth replantation and a reduced incidence of inflammatory resorption. Moreover the dental literature supports the endodontic treatment at issue to address necrotic tissue as neglect of this condition may lead to a potential lead-in to acute infection. Initial stabilization of the patients injury included endodontic treatment. Treatment beyond that period would not be a part of stabilization of the patients immediate injury. Based on the documentation provided for review the patients symptoms did meet prudent layperson criteria for initial emergency care.  Final Result: The reviewer determined that the patients symptoms did meet prudent layperson criteria for initial emergency care. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in dentistry 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

A female enrollee requested 10-12 sessions of acupuncture services for medical treatment of her back pain. Findings:  The physician reviewer found without documentation of how a condition began, description of subjective complaints, inclusion of the examination findings, positive orthopedic findings, and functional-motor-sensory deficits to be addressed by the care requested, additional acupuncture sessions are not indicated. Also, as the patient underwent prior acupuncture, the number of completed sessions and the benefits obtained, should be included in the request for acupuncture, in order to support an indication for additional care. In sum, the requested 10-12 sessions of acupuncture services do not meet the clinical criteria for medical necessity.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested substance use partial hospitalization program (PHP) services for medical treatment of his alcohol dependency.   Findings:  The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines suggest that PHP should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. The records indicate that if the patient was discharged early, he would have been at high risk for relapse and he continued to require safe and stable living environments in order to develop  recovery skills. Consistent with these findings, the PHP services were medically necessary for treatment of this patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

A female enrollee requested balloon sinus ostial dilation for medical treatment of her chronic sinusitis.  Findings:  Three physician reviewers found that no computed tomography (CT) scan was reportedly performed in this patient. The records do not demonstrate that the patient has been medically treated prior to consideration for surgery.  All told, the medical records suggest that the requested balloon sinus ostial dilation is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested digital breast tomosynthesis  for medical  evaluation of her risk for breast cancer.   Findings:  Three physician reviewers found that in this particular patient, she has had a prior mammogram which noted dense fibroglandular breasts. This was again noted on the most recent mammogram. Digital breast tomosynthesis is rapidly becoming a standard tool in this clinical setting. Consistent with these findings, breast tomosynthesis was likely to have yielded additional data helpful in evaluating this patients medical condition beyond that expected with standard therapies.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested digital breast tomosynthesis (77063) for medical evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical literature indicates that the use of this additional technique may result in earlier detection of small breast cancers as well as a decrease in call back rates for diagnostic work-up.  Thus, the addition of digital breast tomosynthesis to screening digital mammography was likely to be of greater benefit for this patient than other available modalities.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a 12 week course of Harvoni for medical treatment of her hepatitis C virus.   Findings:  Two physician reviewers found that according to the recent joint guidelines by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for treating HCV, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to nonliver-related comorbid conditions.  Based on published evidence of safety and efficacy in the peer reviewed literature, and clinical guidelines, Harvoni is medically necessary for treatment of the patients HCV genotype 1.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Harvoni for medical treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Therefore, Harvoni should be approved for 12 weeks in this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Sovaldi 400 mg for 24 weeks for medical treatment of her chronic hepatitis C virus genotype 3.   Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score.   The requested 24 week course of Sovaldi 400 mg tablets is supported as medically necessary for treatment of this patients hepatitis C virus infection.