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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Synvisc One injection and Synvisc One injections, one every six months for the treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The evidence-based literature supports the use of repeat series of viscosupplementation injections as safe and effective for the treatment of pain in patients with osteoarthritis of the knee when significant improvement in symptoms has been achieved for six months or more and symptoms recur.  There is a lack of reliable evidence that any one brand of hyaluronic acid is superior to other brands for medically necessary indications.  In this patients case, there is a lack of evidence indicating that she was intolerant to, or had failed other hyaluronic acid injections.  While repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee are supported by the medical literature, future authorization should be based on response to prior injections.  A blanket future approval would not be medically appropriate. Therefore, the requested Synvisc One injection was not medically indicated.  Also, Synvisc One injections, one every six months are not medically necessary for the treatment of this patient. 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 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 Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. 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 parent of an enrollee has requested chemical dependency residential treatment center (RTC) services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that according to the treatment team notes the patient needed treatment at the residential level of care because he lacked sufficient insight and coping strategies to prevent relapse if discharged. However, subsequently, the patient had made considerable progress in treatment and had changed considerably since admission. The notes indicate that he had gained both insight and coping strategies that would allow him to transition to a lower level of care. In addition, the notes indicate that the family was very engaged and working hard as well. Therefore, the recovery environment was much more conducive toward helping him to maintain sobriety. The patient no longer qualified for the need for 24-hour daily structure and could have been safely treated at a lower level of care. As such, chemical dependency RTC services were medically necessary initially, but not thereafter. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent 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:   The parent of an enrollee has requested shoe inserts for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  Flatfoot can be divided into two general categories, flexible and rigid.  In flexible flatfoot, the collapsed arch is present only when the patient bears weight.  In rigid flatfoot, the arch is fixed in position regardless of weight-bearing status.  According to the literature, symptomatic flatfoot requires treatment. Options include activity modification, proper shoes and orthoses, stretching and strengthening exercises, and nonsteroidal anti-inflammatory medications.  Surgery may be considered if all other treatment options fail.  This patient has been using orthotics for a significant period of time, with improvement in pain and facilitation of activities.  The literature supports the utility of orthoses in this patient population, particularly regarding prevention of surgical intervention.  All told, the requested shoe inserts are medically indicated for the treatment of this patient.   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 pediatrics with sub-specialty certification in pediatric critical care 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 Daklinza and Sovaldi for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  This patient is interferon-ineligible for multiple reasons.  In treatment-naive, interferon-ineligible, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  For these reasons, Daklinza and Sovaldi are medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: The parent of an enrollee has requested Pristiq for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient is treatment naive for depression and anxiety. Pristiq (desvenlafaxine) is the dextro isomer of venlafaxine and is not approved by the U.S. Food and Drug Administration (FDA) for use in adolescents. In addition, the provider has recently started the enrollee on a different medication. Therefore, there are other medications available that are FDA approved for this patient. Given that Pristiq is not FDA approved for treating this patients behavioral health conditions and there are other medications that are FDA approved in this clinical scenario, the requested medication is not medically necessary.   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 psychiatry with sub-specialty certification in child and adolescent 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:  The parent of an enrollee has requested group social skills speech therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The medical literature supports the use of social skills interventions for children with social communication disorders.  As noted by researchers, several evidence-based social skills interventions are emerging, including peer mentoring, social skills groups, and video modelingresearch supports the need for multimodality and individualized treatment programs.  In this patients case, she has a history of mixed receptive expressive language delay and continues to demonstrate deficits in pragmatic language.  The literature supports involvement in peer mentoring and social skills groups for children with pragmatic language impairment (social communication disorder).  All told, group social skills speech therapy is medically indicated for the treatment of this patient. 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 pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acute inpatient hospital services for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was hospitalized for the treatment of multiple injuries.  He underwent surgical fixation of fractures and treatment of multiple lacerations.  He remained stable during the period of care at issue.  The documentation supports that he was stable with normal vital signs and without complications.  He was tolerating an oral diet, voiding and ambulating.  The patient could have been safely treated at a lower level of care.  All told, acute inpatient hospital services on the dates in question were not medically indicated 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 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 cervical fusion for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The patients pain and distribution of numbness is consistent with C8 spinal nerve root dysfunction.  However, there are motor deficits referencing higher levels in the cervical spine.  She has well-documented symptoms of several years duration.  It is unlikely that physical therapy measures will provide lasting benefit in this patients case.  The current medical evidence supports the requested services for the treatment of this patient.  All told, the requested cervical fusion is medically indicated for the treatment of this patient.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for Forteo. Teriparatide (Forteo) is approved by the U.S. Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture. Teriparatide reduces the risk of vertebral fractures by about 65% and non-vertebral fragility fractures by about 53% in patients with osteoporosis, after an average of 18 months of therapy. These results are superior to other osteoporotic agents available. In this case, teriparatide (Forteo) is medically necessary for this patient, who has experienced severe bone loss. The patient is at high risk for fracture, loss of height, chronic pain and possible nerve compression damage should she develop compression fractures in the spine. It is best standard of care to prevent fractures and comorbidities by providing her the best therapy available. Furthermore, choosing a bisphosphonate or denosumab prior to teriparatide would hinder the optimal effect that can be obtained with teriparatide as first-line of therapy in this case. 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 endocrinology 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 parent of an enrollee has requested a cranial orthotic device (molding helmet, DOC band) for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that positional plagiocephaly and deformational brachycephaly are broad terms used to encompass abnormal head shape due to a wide variety of etiologies.  Because plagiocephaly and brachycephaly are extremely variable in etiology and presentation, strict guidelines for management are not possible.  The American Academy of Pediatrics published prevention and management guidelines for positional skull deformities in infants.  The authors noted skull molding helmets are an option for patients with severe deformity or skull shape that is refractory to therapeutic physical adjustments and position changes. Surgery is rarely necessary but may be indicated in severe refractory cases of deformational plagiocephaly or in patients with craniosynostosis.  In this patients case, the records document abnormal head shape with brachycephaly compounded by plagiocephaly. Anthropometric measurements indicate severe brachycephaly and plagiocephaly is less pronounced.  Based on measurements, recommendations in the literature, and standard of care, a cranial remolding orthosis is medically necessary.  All told, the requested cranial orthotic device (molding helmet, DOC band) is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested device 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 pediatrics with sub-specialty certification in pediatric critical care 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 parent of an enrollee has requested a surgical consultation for gender reassignment surgery for treatment of the enrollees gender dysphoria.  Findings:  The physician reviewer found that the patient has been transitioning to the male gender. The patient appears to have benefited from this transition, although he is noted to have severe dysphoria.  His provider has recommended surgical consultation. The proposed consultation is considered medically necessary as the next step in the treatment of this patients gender dysphoria. The surgical concept of female-to-male reassignment surgery is well established within the community of plastic surgeons as demonstrated in the references cited above. Each patient must be reviewed on a case-by-case basis to determine medical necessity.  In this patients case, medical necessity for the requested consultation has been sufficiently established by the submitted medical documentation, as the patient has identified as male and has already taken both reversible and irreversible steps toward his transition.  His diagnosis of gender dysphoria has affected his function psychologically and his initial surgical transition has already been noted to have provided some functional benefit. The patient has a functional deficit related to his gender dysphoria and the appropriate next step is further consultation to consider treatment options. As such, the proposed surgical consultation is medically necessary for treatment of the patients gender dysphoria. 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 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.