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

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for power operated vehicle (POV) scooter. Findings:  The physician reviewer found that the requested power operated vehicle is not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient has chronic back pain and an antalgic gait, however the wheelchair evaluation indicates she can ambulate household distances. The provider also states that patient is able to use a cane and a manual wheelchair within her home. The documentation does not reveal that the patient is unable to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming, and bathing in her home. Moreover, there is no evidence that her mobility limitation either within the home or outside the home cannot be sufficiently resolved by the use of an appropriately fitted cane, walker or manual wheelchair. Her shoulder examination revealed full range of motion, no impingement signs and sufficient strength. Therefore the documentation does not support that the patient would be unable to use a manual wheelchair. For these reasons, the requested POV scooter is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: The patient has requested authorization and coverage for Harvoni for 12 weeks.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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. This applies to all patients, regardless of fibrosis. The guidelines recommend that non-cirrhotic treatment naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for eleven (11) visits for home health services/hospice nurse for treatment of the enrollees cystic fibrosis. Findings:  The physician reviewer found that the documentation states this patient is homebound and requires the services of a registered nurse (RN) who specializes in home health or hospice care to change peripherally inserted center catheter (PICC) line dressing weekly as well as perform standard laboratory testing. Consistent with the Centers for Medicare and Medicaid Services (CMS) recommendations, the requested eleven (11) visits for home health services/hospice nurse are supported as 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 internal medicine with sub-specialty certification in hospice and palliative 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 authorization and coverage for Otezla. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. This patient has tried and failed therapy using topical steroids. However, there is no documentation of treatment failure, intolerance, or contraindication to the use of the preferred first-line agents, such as methotrexate, acitretin, Enbrel or Humira. The fear of immunosuppression does not represent a true contraindication to the use of these medications.  There are preferred alternative therapies available for this patient.  All told, Otezla is not medically necessary 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for pelvis magnetic resonance imaging for evaluation of the enrollee's rising prostate specific antigen (PSA) level. Findings:  Three physician reviewers found that while there are emerging studies to support magnetic resonance imaging (MRI) in the management of prostate cancer, there is still a relative paucity of reliable data. Further studies are recommended. This patient has not had an initial biopsy. At this time, standard transrectal ultrasound and guided biopsy of prostate remains to be the initial diagnostic modality.  In sum, pelvis MRI is not likely to be more beneficial than the other standard methods for the evaluation of this patients medical condition. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in urology and are actively practicing. The reviewer are 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 reimbursement for DecisionDx-Melanoma testing for evaluation of the enrollees cutaneous melanoma. Findings:  The physician reviewer found that the DecisionDx-Melanoma assay tests the tissue genetics of the melanoma and has the ability stratify whether a thin melanoma is high risk for metastasis. This test has shown some accuracy determining risk of metastasis in thin melanomas. However, the results of the test are indeterminate at this time. The treatment of this patient would not change based on the results of the testing. The testing at issue is not considered the standard of care. There is a lack of medical literature to support its use in the care of patients with thin melanomas to effect health outcomes. Given the lack of published data supporting its use, DecisionDx-Melanoma testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in dermatology 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 patient has requested authorization and coverage for Orthovisc (or equivalent) viscosupplementation knee injections for treatment of the enrollees bilateral knee osteoarthritis. Findings:  The physician reviewer found that there is good evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. Researchers conducted a systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. The authors reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. 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. Findings:  The physician reviewer found that the physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. During the dates of service in dispute, the records indicate that the patient had stabilized and was eating appropriately. Her medical status was intact, and she appeared psychiatrically stable. She was not exhibiting severe mood, anxiety or psychotic symptoms and was not engaging in self-harm type behaviors. The progress notes indicated that the patient had cognitive issues. Throughout her stay, it did not appear that these cognitive issues improved, and it appears that she may have been at her baseline level of cognitive function. Further residential care would not be expected to improve these cognitive issues. As noted in the psychological evaluation, it was likely that the patient would need continued assistance after residential treatment was completed. It appears that she had reached maximum benefit from her residential stay. The progress notes indicated the patient went on passes with family members, and there was no indication of difficulties on these passes for any severe behavioral issues. The records indicated that the patient could have been treated safely and effectively in a less restrictive setting during the dates of service in dispute. The medical literature indicates that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of anorexia nervosa. The residential treatment center progress notes indicate that the patient was cooperative in treatment, and the records demonstrate that less restrictive treatment would have been appropriate. All told, 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Contrave. Findings:  The physician reviewer found that the request for Contrave is not medically necessary for treatment of the patients medical condition. Contrave was approved by the U.S. Food and Drug Administration (FDA) as an adjunct to diet and exercise in patients with a body mass index (BMI) greater than 30 or greater than 27 in the presence of at least one weight-related comorbidity like hypertension, type 2 diabetes or dyslipidemia. Due to Contrave containing bupropion, the FDA warns of psychiatric disorders, especially in the young adult population. In addition, a randomized trial designed to assess cardiovascular outcomes of bupropion and naltrexone in overweight or obese patients was terminated early and the cardiovascular safety remains unknown. In this case, the patient is treated with bupropion and also takes antidepressant medication. The addition of Contrave to this patients current medication regimen may cause adverse effects. All told, Contrave has not been established as 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing. Findings:  The physician reviewer found that based on the review of the current medical literature, advanced lipoprotein testing is not definitively demonstrated to be more beneficial than the standard laboratory tests for patients in this clinical setting. There is a lack of evidence to support that advanced lipoprotein testing improves a patients health outcomes when compared to standard lipid testing. In addition, in this patients case, the medical records provided for review do not indicate how the ordering provider intended to use the data obtained or how it would be used to affect treatment or reduce cardiovascular risk. The provider would have been able to base treatment options by using a standard lipid profile alone. A standard lipid testing includes total cholesterol, low density lipoprotein, high density lipoprotein, and triglyceride levels. In sum, the advanced lipoprotein testing was not likely to have been more effective than the other available methods of for the evaluation of this patient.  Final Result: All 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: Physician reviewers 1,2 & 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for the Game Ready recovery technology device for treatment of the enrollees articular cartilage disorder. Findings:  Three physician reviewers found that the current peer-reviewed medical literature does not include any randomized controlled trials studying the effects of combined cyclic compression and cryotherapy in major hip surgery. This patient underwent left hip arthroscopic labral repair, acetabular rim resection, and femoral CAM resection and was prescribed a Game Ready device for home use. She reported prior benefit with the use of the Game Ready device during post-operative physical therapy following prior left hip surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device for this patients condition.  Final Result: The reviewers determined that the requested device 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: Reviewers 1, 2 and 3 are board certified in orthopedic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility stay including services for physical therapy, speech therapy and occupational therapy provided for treatment of the enrollee who has a history of strokes. Findings:  The physician reviewer found that functional impairments due to acquired brain insults such as meningitis, encephalopathy and non-traumatic intracerebral hemorrhage can be profound. Nevertheless, some recovery is expected with time, such as natural recovery processes. The medical studies suggest that many of these impairments are amenable or addressable by compensatory measures and directed rehabilitation efforts. The role of inpatient rehabilitative care for patients with significant functional deficits following stroke is relatively well established in the medical literature. In the present case, the patient has had multiple cerebral insults due to toxic metabolic encephalopathy, strokes and intracerebral hemorrhage. The patient has undergone extensive rehabilitation, but has made very limited gains over a prolonged period of time. She continues to be dependent for mobility and to require significant assistance for self-care. Based on her records, she has otherwise medically stabilized and does not require skilled nursing or medical services in an inpatient hospital setting. The patients needs, overall, were and are at the custodial level of care. The need for further skilled nursing facility level care is not supported by the available records. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation 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 patient has requested reimbursement for the residential treatment center (RTC) services for treatment of the enrollees polysubstance abuse. Findings:  The physician reviewer found that the records indicate that this patients post-acute withdrawal symptoms were mild in nature. He was not a danger to himself or others. He was cooperate and not hostile or aggressive towards others. His activities of daily living (ADLs) were not impaired. He was engaged in the program. There were no emotional, behavioral, or cognitive factors requiring RTC level of care services. His medical conditions were chronic and could have been safely and adequately managed in an outpatient setting, as could the medication changes that occurred. His relapse risk was rated as moderate by staff. Although his wife was not supportive, his brothers and mother participated. The patient was seeking a sober living environment. He had not had treatment at a lower level of care in the previous year. His treatment and recovery could have continued at an ambulatory lower level of care in conjunction with community based services such as Alcoholics Anonymous (AA). 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 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.