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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl 50 mcg/hour patches by transdermal route (15 patches for 30-day supply) for treatment of his chronic pain syndrome.  Findings:  The physician reviewer found that he documentation does not provide objective treatment goals for pain and no function were noted for the requested medication. Chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. The CDC also states clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible. The 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. In this patients case, tolerance has taken place since the start of the narcotics. The patients pain scores have remained the same despite increases in the amount of opioid he is taking. Ketamine infusions have been done and the 100% relief noted for three to four weeks were not corroborated with a decrease in any opioid usage. The provider has established no clear objective goals with this high of a dose of opioid. Moreover, the increases appear to have been done only on the basis of pain levels. There was no mention of behavior therapy in the documentation despite much research to support its use. Finally, not all non-opioid medications classes have been optimized or tried. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for Synvisc injection for treatment of severe right knee degenerative joint disease. Findings:  The physician reviewer found that there is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis with long-lasting benefits as compared with intraarticular corticosteroids. Evidence from studies of repeat courses of hyaluronic acid demonstrates an improvement in pain or function lasting up to 40 months (12 months after the last injection cycle), a reduction in use of concomitant analgesia by up to 50%, and suggests that there may be a delay in the need for total knee replacement of around two years. Researchers reported that their comparison of intraarticular hyaluronic acid with other non-operative treatment modalities for knee osteoarthritis shows that the current highest level of evidence suggests that intraarticular hyaluronic acid is an effective treatment option for knee osteoarthritis. A review of this patients medical records indicate that acetaminophen as well as NSAIDs have been tried and failed. The patient indicates that the osteoarthritis of the right knee was aggravated by the right hip revision surgery. She received physical therapy without improvement. The pain is constant and interferes with her ability to perform activities of daily living. Corticosteroid injection did not provide adequate relief. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging to determine if there is sciatic nerve damage for evaluation of his history of lower back pain. Findings:  The physician reviewer found that the medical literature supports obtaining an imaging study when it will change the course of therapy.  The correlation between magnetic resonance findings and clinical symptoms requires strict clinical correlation. The American College of Radiology (ACR) has established appropriateness criteria to evaluate various clinical presentations, including low back pain.  The guidelines indicate that imaging patients with acute low back pain (LBP), of less than six weeks duration and no red-flag symptoms provide no clinical benefit (ACR Appropriateness Criteria). In another publication, the ACR states, Interestingly, the size and type of disc herniation and location and presence of nerve root compression were not related to patient outcome. A recent study found no statistically significant difference in primary outcome after 1 year for older adults who had spine imaging within 6 weeks after an initial visit for care for LBP versus similar patients who did not undergo early imaging It is well documented that imaging patients with chronic LBP is often not beneficial and similar imaging findings are often present in asymptomatic individuals. Additionally, patients with new episodes of LBP and previous MRI scans are unlikely to detect changes in disc protrusion, annular fissures, high-intensity zones, or end-plate signal changes with repeated MRI. The medical literature and the guidelines recommend conservative therapy, both pharmacologic and nonpharmacologic, prior to initiating further imaging studies. This patient is documented to have a relatively new onset of low back pain, and in the absence of pre-existing conditions such as a tumor or indications of an acute infection, the most prudent approach is to proceed conservatively. The documentation does not show that he has exhausted conservative management.  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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for duloxetine HCL 60 mg three times per day for treatment of her neuropathic pain. Findings:  The physician reviewer found that the medical records provided for review document specific antidepressant and anticonvulsant medications have been tried and failed or demonstrated untoward side effects. As such, the medical records indicate that duloxetine is supported for treatment of this patients neuropathic pain. Duloxetine has shown effectiveness for wide variety of neuropathic pain conditions and that dosage of 180 mg per day in select cases has shown benefit when lower doses were not maximal in benefit. The records support that a dosage of 180 mg per day is needed to achieve functional benefit. Lower dosage results in the patient not being able to function. It is reasonable for this dose to be used when other lower doses failed and other medications have failed. 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 neurology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Singulair 10 mg tablets, instead of its generic equivalent. Findings:  The physician reviewer found that Singulair and generic montelukast were approved by the U.S. Food and Drug Administration (FDA) in 2012. To obtain FDA approval, a generic manufacturer has to make a product with the same manufacturing, packaging, and quality standards as the name-brand product. The study by Zaid and colleagues confirms the interchangeability and comparative effectiveness of generic and brand montelukast. In that study, the two preparations of generic and brand montelukast were found to have the same bioequivalence with comparable safety and efficacy profile in healthy volunteers. Hence, substitution of one for the other is the standard of care. In addition, there is a lack of evidence provided demonstrating that generic montelukast is ineffective for this patient. All told, the request for Singulair 10 mg tablets, instead of its generic equivalent 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: Physician reviewer number is board certified in internal medicine with sub-specialty certification in pulmonary disease and 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested sacroiliac joint fusion for treatment of the his sacroiliac pain.  Findings:  Three physician reviewers found that according to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS) well selected patient can benefit from sacroiliac joint fusion. According to the ISASS guidelines, patients who have significant sacroiliac joint pain confirmed with at least three physical examination maneuvers that stress the sacroiliac joint, have confirmation that the sacroiliac joint is the pain generator with 75% or greater relief with fluoroscopically guided diagnostic intra-articular sacroiliac joint block using local anesthetic, and have failed to respond to at least six months of non-surgical treatment consisting of non-steroidal anti-inflammatory drugs and/or opioids and one or more of the following: rest; physical therapy; and sacroiliac joint steroid injection, may be a good candidate for sacroiliac joint fusion. This patient has pain rated 8/10, confirmed by three physical examination maneuvers that stress the sacroiliac joint, and his pain interferes with his ability to perform activities of daily living. In addition, the patient had three diagnostic sacroiliac joint injections which gave him greater than 75% relief and has failed to respond to more than six months of conservative therapy. Moreover, additional or alternative diagnoses that could be responsible for the patients ongoing pain or disability have been ruled out. Final Result: The reviewers determined that the requested surgery is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in orthopedic surgery 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for circumcision for treatment of his irritation of the foreskin. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient has irritation of the foreskin.  However, there is no documentation of recurrent urinary tract infections, phimosis, penile cancer, recurrent posthitis or balanitis or traumatic injury to the foreskin. The current medical literature does not support circumcision in this clinical setting. Final Result: The reviewers 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ NuSpin for treatment of his short stature. Findings:  The physician reviewer found that the records provided for review do not support the medical necessity of the requested Nutropin AQ NuSpin for treatment of this patients short stature. Specifically, there are no growth curve and no statement as to the patients genetic target. This is important because the bone age determination suggests the adult predicted height is around 66 to 67 inches and the bone age is not delayed. In patients with GH deficiency, the bone age is characteristically quite delayed. That is a prediction based on a bone age of 13 years at a chronologic age of 14 years 2 months. In addition, the results of the growth hormone stimulation test done in March 2015 demonstrated an abundant growth hormone response, with the peak to 31.0 ng/mL, which might be interpretable as indicative of resistance to growth hormone such as occurs in Laron dwarfism or IGF-1 receptor defects. If this is the case, and is confirmed with a low IGF-I and IGF-BP3, then therapy with Increlex would be more appropriate. However, if he has true resistance to growth hormone, it would have been expected that he would have presented sooner with far more significant short stature, and lower IGF-1 and he would not have any response to exogenous growth hormone therapy. On balance, the growth and stimulation test with the response up to 31.0 ng/mL represents a variation of the normal range and is not indicative of growth deficiency or growth hormone resistance. 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 pediatrics with sub-specialty certification in pediatric endocrinology 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 Victoza 3-PAK for treatment of her uncontrolled diabetes mellitus. Findings:  The physician reviewer found that Victoza is a glucagon-like peptide-1 receptor analog (GLP-1 RA). Glucagon-like peptide-1 (GLP-1) based therapies affect glucose control through several mechanisms, including enhancement of glucose dependent insulin secretion, slowed gastric emptying, and reduction of postprandial glucagon and of food intake. These agents do not usually cause hypoglycemia in the absence of therapies that otherwise cause hypoglycemia. Victoza is indicated in the treatment of diabetes mellitus and obesity. The recent American Diabetes Association (ADA) standards of care for the treatment of diabetes recommend that a patient-centered approach should be used to guide the choice of pharmacologic agents. This patient had a regimen that worked very well for her as demonstrated by her ability to lose weight, control her diabetes and blood pressure to goals, and allowed her to discontinue insulin and antihypertensive therapy. The patient completed an adequate trial of Tanzeum, without benefit.  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 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 AmniSure testing for evaluation of the enrollees pregnancy. Findings: All three physician reviewers found that this patient presented with concern of rupture of membranes. Traditional testing in this setting includes three elements from an evaluation of vaginal fluid: ferning, nitrazine testing and pooling.  Tests such as AmniSure testing have been shown to have higher false positive rates. The current medical evidence supports the use of AmniSure testing in cases where traditional testing is equivocal or the situation is high-risk. In this case, the patient presented with no risk factors that would make using traditional testing to rule out rupture of membranes unsatisfactory. There is no indication in the medical records that a traditional evaluation was conducted or was inconclusive. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in obstetrics and gynecology 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: The parent of an enrollee has requested reimbursement for residential mental health and substance abuse treatment services provided for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was very cooperative in treatment. On numerous occasions, she was noted to be helpful towards her peers and in a joyful mood.  The records indicate that the patient was cooperative with staff, and her activities of daily living appeared intact. The medical records do not support active suicidal ideation or psychosis at the time the patient was admitted to the residential treatment center or during the disputed period. The records indicate the patient was open to receiving therapy to aid with her behavioral health issues. The records do not indicate that she had failed intensive outpatient services prior to her admission to the residential treatment center. There were no significant or severe behavioral problems noted during her stay. Based on the records, the patient did not need the restrictiveness of a residential psychiatric treatment facility in order to receive her care. The treatment goals listed could have been accomplished on an outpatient basis. Residential treatment is used for acute stabilization of psychiatric conditions. It is not evidenced-based for long-term type treatment. Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting. 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 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: An enrollee has requested authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of the enrollees hepatitis C virus. 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.