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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia care (MAC) for treatment of the enrollees medical condition. The physician reviewer found that the services at issue were medically necessary for the patients screening colonoscopy. According to Abel and Eisenkraft Myasthenia gravis is a disease of great significance to the anesthesiologist, because it affects the neuromuscular junction. Anesthetic concerns for patients with myasthenia gravis include the interactions among the disease, the disease treatment, and the medications used for anesthesia. When sedating it is preferred to use ultrashort- or short-acting sedatives, hypnotics, and anesthetic agents to minimize respiratory depression. If premedication is necessary, the smallest effective dose should be administered incrementally with continuous monitoring for signs of bulbar weakness and respiratory compromise. This is difficult for the gastroenterologist as continuous visual monitoring of the patient is required. In addition, the medical literature suggests that propofol is the preferred agent for endoscopic procedures. Given the anesthetic concerns for this patient with myasthenia gravis, the MAC services were medically necessary for treatment of the patients medical condition. 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 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 24 weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1.  Findings:  Three physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. 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 FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. Therefore, although Harvoni is clinically appropriate in this setting, the requested duration of 24 weeks of therapy is not medically necessary given the support in the guidelines which recommends treatment with Harvoni for 12 weeks. Final Result: Three reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The 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 Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection.  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: The three reviewers are board certified in internal medicine. 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 monitored anesthesia care (MAC) services during a colonoscopy for evaluation of his recurrent diverticulitis and colon polyp. Findings:  The physician reviewer found that the medical literature reports that conscious sedation is safe and effective for patients who need minor surgery or a procedure to diagnose a condition. Conscious sedation is often utilized for colonoscopies. According to the medical literature, indications for MAC services include the nature of the procedure, the patients clinical condition and/or the potential need to convert to a general or regional anesthetic. In this patients case, there is a lack of clinical documentation supporting an indication for MAC services instead of general anesthetics or conscious sedation. Moreover, there is no evidence that the patient has required MAC previously during prior colonoscopies or surgical procedures to warrant continued use of MAC services. All told, MAC services during a colonoscopy were not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that although there is a lack of long term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol the addition of the technique has gained worldwide popularity among providers due to an associated significant decrease in callbacks and increased detection of small cancers.  Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Consistent with these findings, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology 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 a 3.0 Tesla magnetic resonance imaging (MRI) of the thoracic spine, cervical spine and lumbar spine for evaluation of her thoracic spine pain.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. In this clinical setting, the medical literature does not support the use of Tesla 3.0 MRI. Moreover, a 1.5 Tesla MRI is the standard of care for the re-evaluation of this patients spine. There is a lack of medical literature supporting the medical necessity of a 3.0 Tesla study for chronic back pain. Based on the medical literature and clinical documentation provided, a 3.0 Tesla MRI of the thoracic spine, cervical spine and lumbar spine was not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 with sub-specialty certification in interventional radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested whole genome sequencing (WGS) for evaluation of his progressive fatigue, respiratory and swallowing dysfunction, muscle soreness, mild weakness, cramping and twitching.  Findings:  Three physician reviewers found that according to the documentation submitted for review, the patient has a complex history likely due to an underlying genetic explanation. However, there is a lack of published literature that demonstrates that WGS has a significantly better detection rate than whole exome sequencing (WES) in this clinical setting. Moreover, there is a lack of research that compares the likelihood of finding a clinically significant variant on WGS compared with WES. Many studies lump WES and WGS together, referring to them as WES/WGS since both provide the same kind of data. However, there is a lack of data demonstrating that WGS specifically would be more beneficial. Therefore, the requested services are not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three 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: Two reviewers are board certified in pediatrics with sub-specialty certification in clinical genetics and are actively practicing. One reviewer is board certified in clinical genetics and clinical biochemical genetics and is 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: The parent of an enrollee requested Genotropin growth hormone (GH) therapy for treatment of the enrollees idiopathic short stature. Findings:  The physician reviewer found that according to recent guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations (SDs) below the mean for age or more than 2 SDs below the mid-parental height percentile; (2) growth velocity in less than 25th percentile for bone age; (3) bone age more than 2 SDs below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient does not have evidence of biochemical GH deficiency. The height prediction, while shorter than the mid-parental target height, is not short enough to warrant a trial of GH treatment for idiopathic short stature based on current U.S. Food and Drug Administration (FDA) indications.  Consistent with these findings, the requested Genotropin GH therapy is not medically necessary for treatment of this patients short stature. 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 and 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested the Colon Sentry test for evaluation of her risk of colorectal cancer.  Findings:  Three physician reviewers found that the Colon Sentry test performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a lack of data in the peer-reviewed literature supporting the testing at issue. Moreover, the testing at issue is not approved by the U.S. Food and Drug Administration nor supported by national guidelines. Therefore, the Colon Sentry test performed was not likely to be more beneficial for treatment of the patients medical condition than standard therapy such as a colonoscopy. Final Result: Three 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: Two reviewers are board certified in medical oncology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is 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 Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that in managing patients with chronic HCV, denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on HCV does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. For the reasons provided, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients HCV. 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested Orthovisc injections for treatment of her left knee osteoarthritis.   Findings:  Two physician reviewers found that viscosupplementation has been used for treatment of osteoarthritis of the knees. However, the results in clinical trials have been mixed, and the effects have been short lived. More recently, studies have been reported in the literature indicating a change in the guidelines associated with use of viscosupplementation for osteoarthritis of the knees. According to the study published, 89 trials involving 12,667 adults were studied. The authors concluded that, in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. Similarly, the revised clinical practice guideline for knee osteoarthritis indicates the most significant change is a strong recommendation against the use of intra-articular hyaluronic acid for symptomatic knee osteoarthritis. Overall, the current evidence suggests that hyaluronic acid injections may be effective in mild tibiofemoral arthritis by changing the viscosity of the synovial fluid and may be used to delay a total knee arthroplasty. However, as the arthritic changes progress with the aging process, the injections are no longer effective. Further, the guidelines do not recommend its use in patellofemoral arthritis. In light of the foregoing, the requested Orthovisc injections are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are 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 magnetic resonance imaging (MRI) of the lower back for evaluation of his back pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The clinical documentation submitted for review does not demonstrate that the patient has been treated with a trial of physical therapy. In addition, the documentation submitted for review does not demonstrate the patient has unequal reflexes on physical examination or has one-sided weakness. Based on the medical literature and clinical documentation provided, the request for MRI of the lower back is not medically necessary for evaluation of the patients medical condition. 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 with sub-specialty certification in interventional 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested ambulance services on an emergent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought ambulance transport services on the date in question. Upon review of the submitted medical records, the patient presented with complaints of being unable to sleep for the last three weeks without reported chest pain, shortness of breath, pain, weakness, headache, loss of function, nausea, vomiting, or diarrhea. The patients pain scale was 0 out of 10. In a letter from the patient, he indicated that he felt like he was having a heart attack. Although the notation on the EMT report notes that there were heart problems this was from the patients history and not an acute complaint on the date in dispute. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services in question did not meet prudent layperson criteria for emergent care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergent care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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.