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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient psychiatric services treatment for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that formal thought disorders comprise the most serious of psychiatric conditions and this patient has a particularly debilitating illness burden. This patient has a court-ordered conservator. He has recurrent suicidal behavior, depression and disorganized thinking. His most recent medication regimen consists of antidepressant therapy and 23 antipsychotic tablets every day, including clozapine which is a medication typically reserved for the most severe cases. He survived a high-lethality suicide attempt. He has prior history of suicidality and psychiatric hospitalization. He has multiple risk factors and warning signs for suicide and has reportedly asked his family to buy a gun so he can kill himself upon discharge. Finally, the psychiatric consultant has determined that admission to an acute inpatient unit and treatment with electroconvulsive therapy is indicated. All of these factors support psychiatric placement at the acute level of care. The risk for suicide spikes the first week after discharge. In addition, the patient has been engaged in active care during the hospital course yet remains symptomatic. The acute inpatient setting would be reasonably expected to improve the patients condition, while preventing a more serious episode of illness, and represents a safe and appropriate disposition consistent with good medical practice. Additionally, ECT would be a logical treatment intervention in this particular case and is medically necessary. Final Result: The reviewers 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for rabeprazole. Findings:  The physician reviewer found that : the documentation provided does not support the medical necessity for the requested medication in this clinical setting. American College of Gastroenterology guidelines recommend twice-daily therapy when once-daily therapy is insufficient to control gastroesophageal reflux disease symptoms, including in patients with esophagitis .  The medical literature does not show any difference between rabeprazole and most other proton pump inhibitors (including pantoprazole, omeprazole, and lansoprazole) for gastroesophageal reflux disease or esophagitis. As such, it is unlikely that trial of formulary alternatives will be helpful after the patient has failed omeprazole and esomeprazole .  However, this patient has not attempted Dexilant.  Dexilant, unlike all other proton pump inhibitors, is released in an extended fashion. A study  notes that this delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors. A significant majority of patients (88%) on other proton pump inhibitors twice daily were able to control symptoms on Dexilant once daily . Other medical studies have shown that Dexilant is also more effective to treat symptoms than alternatives such as esomeprazole .  For these reasons, rabeprazole is not supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 authorization and coverage for Zepatier 50 mg-100 mg, one tablet daily for 12 weeks for treatment of the enrollees 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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including 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. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the requested medication regimen 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 reimbursement for Decision DX Melanoma Assay for evaluation of the enrollees malignant melanoma.Findings:  The physician reviewer found that the prognosis of cutaneous melanoma has classically been determined by applying the staging system spelled out by Balch. Mitotic index may also add a bit more to these statistics.  By Balch staging, this melanoma would be staged as a T3aN0, or stage IIA. This would be expected to have a ten-year survival of approximately 64%.  Decision DX is a study of 31 genes in an individuals melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease free rate at five years) or Class 2 (with a 20 to 30% disease free rate at five years). Good correlation between prognosis and Decision DX has been reported in patients undergoing sentinel node sampling, as has this patient. However, it is not clear how the Decision DX five-year data compares to the ten-year Balch data, and whether it can be used to make clinical decisions. 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 internal medicine with sub-specialty certification in medical oncology 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 Euflexxa injections for treatment of the enrollees bilateral knee osteoarthritis. Findings: The physician reviewer found that the benefit of viscosupplementation for more than two series has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation is not U.S. Food and Drug Administration (FDA) approved and is not supported by the Centers for Medicare and Medicaid Services (CMS). Final Result: The reviewer 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 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: The parent of an enrollee has requested authorization and coverage for a bariatric surgery consultation for treatment of the enrollees abdominal pain, obesity, and diabetes mellitus. Findings: The physician reviewer found that the records document that this patient meets the current criteria for consideration of adolescent bariatric surgery, as she has a BMI of 52.8 kg/m2, which is over the threshold of 50 kg/m2. In addition, the patient also has diabetes which would allow consideration for a consultation for bariatric surgery at a BMI of 40 kg/m2 or greater based on standard published guidelines from the International Pediatric Endosurgery Group (IPEG). This patient has failed dietary efforts in the past. This recommendation is for referral to a bariatric surgeon for consultation. Given that bariatric surgery is an elective procedure requiring a multidisciplinary evaluation that can take several months to complete, it is medically supported that this patient be allowed to initiate this process now, given her high BMI. Final Result: The reviewer determined that the requested referral is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in surgery with sub-specialty certification in bariatric 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 minimally invasive decompression procedure. Findings:  The physician reviewer found that in the medical literature, a study performed a randomized controlled trial to evaluate the minimally invasive procedure percutaneous laser decompression versus conventional surgical techniques. The authors reported that there was no indication that the minimally invasive surgery was superior to open surgical techniques. This patient presents with a history of chronic lower back pain. He reported an onset of radicular symptoms in late last year. Clinical examination findings have not documented a focal neurologic deficit. There is imaging evidence of severe multilevel lumbar degenerative disc disease from L1-S1 and facet arthropathy from L1-L4. Conservative treatment has included facet blocks, epidural steroid injection and medications without sustained improvement. Additional conservative treatment has been recommended to include physical therapy. There is no compelling rationale presented to support the medical necessity of referral for laser surgery for this patients condition given the absence of evidence based medical literature support for laser surgery over traditional surgery. Therefore, this requested minimally invasive decompression procedure is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested surgery 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Foundation One gene testing performed.  Findings:  The physician reviewer found that The Foundation One assay is a molecular assay that explores the mutations of an individual patients cancer cells. Currently, there is a lack of convincing evidence that the assay yields results that are reliably clinically beneficial. There are a variety of non-randomized studies exploring the value of molecular profiling which have not demonstrated the efficacy of these analyses . West noted that research is ongoing and there are serious limitations of the available studies. A randomized trial  did not report significant clinical benefit from choosing therapy based on molecular targets versus by the providers clinical judgment. Given these findings, the Foundation One gene testing performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:Physician reviewers 1, 2 & 3are  board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an Orthovisc injection series. Findings:  The physician reviewer found that  The requested  Orthovisc injection series is medically necessary for treatment of the patients medical condition. There is sufficient evidence based peer-reviewed literature that supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. According to a study, hyaluronic acid was found to be better than injected placebo or injected corticosteroids. another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. Similarly,  another study reported that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient presents with bilateral knee pain and a history of bilateral knee osteoarthritis. The patient had failed conservative treatment to include physical therapy, NSAIDs, and corticosteroid injections. In addition, previous Euflexxa and Orthovisc injections in 2013 and 2015 have provided excellent long-term relief of the patient's bilateral knee pain. Therefore, the requested Orthovisc injection series is medically necessary for treatment of the patients bilateral knee osteoarthritis. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Physician 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 reimbursement and prospective authorization and coverage for methadone 10 mg .Findings:  The physician reviewer found that : the records provided for review document that this patient has a history of multiple sclerosis, osteoporosis, and scoliosis, facet degeneration of the lumbar and lumbosacral regions, chronic lumbar radiculopathy, and back pain of lumbosacral region with sciatica. The documentation states that the patient is stable with her current regimen of methadone and is able to perform activities of daily living. The patient signed a medication contract ion the date of disputer. The patient has failed conservative therapy with first-line opioid medications. Further, the patient endorses benefit from the current regimen without side effects. Lastly, the patient is compliant with the current regimen and has a signed opioid contract in place. Therefore, the methadone 10 mg from date of dispute and forward was and is medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was and 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for wearable cardioverter defibrillator vest received. Findings:  The physician reviewers found that there is a lack of support for the device at issue in this clinical setting.  The benefits of the wearable cardiac defibrillator have been the subject of intensive study.  The wearable cardiac defibrillator has not been proven to be of benefit for newly-diagnosed cardiomyopathy.  The American College of Cardiology (ACC) guidelines do not support use of the wearable cardioverter defibrillator vests in this clinical setting.  Permanent implantable cardioverter defibrillators are recommended after a waiting period of 45 to 90 days, but the wearable cardioverter defibrillator has not been proven beneficial.  There is a lack of evidence via randomized trials showing benefit for wearable cardioverter defibrillators over and above that of optimized medical therapy.  Thus, the superior effectiveness of the wearable cardioverter defibrillator vest received has not been demonstrated. Final Result: 2 of 3 reviewers determined that the device at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bidet. Findings:  The physician reviewer found that while hygiene is an important part of the management of PI, there are several options for local care. These options include a sitz bath, a standard or handheld shower head, or even a plastic squeeze bottle, and a hair dryer for drying the area afterwards. There are multiple different topical agents and medical therapies directed at the management of this problem. However, identification of the underlying etiology is also of importance. In patients following this sort of surgery, diarrhea or loose stool is very common. In addition, the more caustic nature of the small bowel contents passing through the anal canal increases the risk of PI. Therefore, dietary management and use of antidiarrheals, as well as local skin protections are as important as hygiene. Therefore, while a bidet is an alternative for use after bowel movement, there are other viable alternatives available for use. For these reasons, the requested bidet is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in rectal 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for bariatric sleeve surgery.  Findings:  The physician reviewer found that indications for bariatric surgery include a body mass index (BMI) of greater than 35 kg/m2 with obesity related comorbidities. Although this patients BMI has been documented at 35.06 kgm2, she requires an extensive evaluation including psychiatric assessment to understand any ongoing issues, including an assessment of her ability to comply with post operative restrictions. The patient has also not reportedly been evaluated for sleep apnea with a sleep study and treatment with continuous positive airway pressure (CPAP) as well as cardiac evaluation, given her coronary artery disease. Given the records provided for review, the requested bariatric sleeve surgery is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the requested surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in 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.