Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Wearable Cardioverter Defibrillator (Zoll LifeVest) for the treatment of his medical condition.  Findings:  Two physician reviewers found that the role of the implantable cardioverter defibrillators in patients with significant left ventricular dysfunction is well-documented. Additionally, the wearable cardioverter defibrillator has been shown to be an appropriate strategy in subsets of patients awaiting permanent implantable cardioverter defibrillator placement. This includes patients with temporary contraindication to an implantable cardioverter defibrillator, such as systemic infection, and patients who are in the immediate post-myocardial infarction period.  Providers rely on clinical judgment and experience when assessing patient risk versus benefit.  There is sufficient support for the device at issue in this clinical setting.  In this patients case, the Wearable Cardioverter Defibrillator (Zoll LifeVest) was likely to have been more effective than other treatment options.   Final Result: Two reviewers determined that the device at issue was 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: The parent of an enrollee has requested 56 hours per week of licensed vocational nurse (LVN) services, early and periodic screening and diagnosis and treatment (EPSDT) for treatment of the enrollees medical condition.  Findings: The physician reviewer found that based upon a review of the information provided, as well as the available medical literature, the request for 56 hours per week of LVN services, EPSDT for the patient is medically necessary. The patient has skilled needs which include medication administration, pulmonary clearance therapies, gastrostomy tube feeding, oral suctioning, and monitoring for oxygen desaturation and airway obstruction related to his underlying respiratory problems and obstructive sleep apnea (OSA), and potential administration of supplemental oxygen and repositioning or stimulation in the event of apnea. His mother is a single mother who works outside of the home seven days a week. Given the absence of a skilled caregiver in the home to meet his needs when the mother is working, the frequency of his gastrostomy tube feeding, his medication administration, and his respiratory care needs, medical necessity for skilled nursing services exists. Additionally, per the documentation provided, it appears the patient was previously approved for 56 hours per week of LVN services. The care needs of the patient do not appear to have changed, so it is unclear as to why it would have been determined that the nursing requirements of the patient have changed. Care of medically complex children such as the patient is a significant source of stress for parental caregivers, and community-based resources like skilled nursing are critical factors that facilitate safe care in the home. Considering the information provided for the review and the available medical literature, the requested LVN services are medically necessary for the patient.  Final Result:  The physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Mobi-C total disc replacement for treatment of his medical condition.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has a history of neck pain and left upper extremity symptoms with left deltoid weakness and no other abnormal findings. Radiation of pain and numbness down the left upper extremity is not compatible with a C5 radiculopathy as C5 does not innervate below the shoulder. In addition, he has not had an examination of the brachial plexus nor the supraclavicular areas to rule out other pathologies. This patient has three levels of degenerative disc disease.  Cervical disc replacement is indicated in single-level degenerative disc disease. Finally, there is a lack of medical literature supporting the long term safety and effectiveness of Mobi-C. All told, the requested services are not likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in orthopedic surgery and is actively practicing. Two reviewers are board certified in neurological surgery 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 skilled nursing care for the treatment of his medical condition.   Findings:  The physician reviewer found that the current medical evidence supports the services at issue in this clinical setting.  Functional impairments due to acquired brain insults, including severe ischemic hemispheric cerebral strokes, can improve with time, but are also amenable to rehabilitation interventions.  In this case, the patient had very profound initial functional deficits.  He has been receiving rehabilitation care for a prolonged period of time.  However, more recently, he has been making significant functional gains.  Based on the records, additional gains in the near future were and are reasonably expected given the gains in self-care and ambulation.  Further skilled nursing care was and is medically appropriate to optimize his recovery.  All told, skilled nursing care was and is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial-breast irradiation for treatment of her medical condition.  Findings: Two physician reviewers found that APBI delivers adjuvant radiation to part of the breast after breast conserving surgery for early stage breast cancer. APBI is controversial, and is not considered standard therapy outside of a clinical trial. APBI is an emerging standard of care for women with low risk of recurrence. The National Comprehensive Cancer Network (NCCN) guidelines state compared to standard whole breast radiation, several recent studies document an inferior cosmetic outcome with APBI. Follow-up is limited and studies are ongoing. In addition, the American Brachytherapy Society does not recommend APBI for women younger than 50. Currently there is a clinical trial studying whole breast radiation therapy compared to partial breast radiation therapy in treating women who have undergone surgery for ductal carcinoma in situ or stage I or stage II breast cancer (NSABP B-39/RTOG 0413 trial). In sum, long-term follow up is needed to ascertain if there is any risk or benefit in the use of APBI with respect to late toxicity and long-term tumor control. Given the controversy surrounding its use, and the fact that whole breast radiation is a safe, and effective standard therapy, APBI would not be considered 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:  All three reviewers are board certified in radiation oncology 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 Sovaldi and Daklinza 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 limited life expectancy due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  The guidelines cite data showing that delay in treatment may result in decreased survival.  For these reasons, the requested treatment with Sovaldi and Daklinza 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for the treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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.  For these reasons, the requested treatment with Harvoni is 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: An enrollee has requested Harvoni for treatment of her hepatitis C virus. 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested psychiatric emergency services on an emergent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. In this case, the patient was experiencing a psychiatric emergency medical condition. Upon presentation, the patient had multiple static risk factors and warning signs of immediate danger to self.  Based on the patients presenting symptoms, he was experiencing a psychiatric emergency medical condition. Final Result: The reviewer determined that the patient was experiencing a psychiatric emergency medical condition. Therefore, the Health Plans denial should be overturned.  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: The parent of an enrollee has requested Genotropin for treatment of the enrollees medical condition. Findings: The physician reviewer found that this patient's growth factors are normal for early puberty, and his provocative growth hormone testing revealed a normal peak growth hormone response.  Thus, he does not have classic growth hormone deficiency.  In the setting of his underweight status and chronic cardiac disease, the patient cannot be classified as having idiopathic short stature.  Longitudinal growth data prior to the age of 14 are not provided.  Thus, it is difficult to determine to what extent that the patients underlying cardiac disease and treatment affected his growth velocity.  The safety and efficacy of growth hormone therapy in a patient with dilated cardiomyopathy and arrhythmia requiring a pacemaker has not been studied in children.  All told, the requested Genotropin is not medically indicated 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin AQ Nuspin 20 injector for the treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a normal height, normal growth factors, and normal bone age.  Thus, he does not meet criteria for growth hormone deficiency.  There is no information on height and weight velocity over time.  Although the patient had low growth hormone levels in response to provocative growth hormone testing, the provocative testing was performed with inadequate sampling.  Typically, response to growth hormone is assayed over two to three hours on multiple samples after administration of each provocative agent.  All told, Nutropin AQ Nuspin 20 injector 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Subsys has not been established. Subsys is not medically necessary in this clinical setting. The requested medication is indicated for malignant pain. The patient has chronic non-malignant pain. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and anti-depressants considered adjunctive to this therapy. If there is poor response to conservative therapy then interventional treatments should be considered. High dose opioids are associated with a high risk of dependence and tolerance, and therefore are not recommended. Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In addition, short-acting opiates are more likely to cause adverse outcomes. Additional researchers reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. For the reasons provided, the patients request for Subsys 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 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 Harvoni for treatment of his hepatitis C virus.  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 virus should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1 patients be treated with Harvoni for 12 weeks. These guideline 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. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.