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

Nature of Statutory Criteria/Case Summary: An enrollee has requested or mental health therapy/care once per week or more frequently than once every month for treatment of her behavioral health condition.  The physician reviewer found that although psychotherapy is not indicated for the core symptoms of attention deficit/hyperactivity disorder, it remains a trusted intervention in the treatment armamentarium for patients with depressive disorders.  Current practice in the United States is focused on aggressive treatment of depression, particularly in the acute phase of the illness in which weekly or even twice-weekly sessions may be indicated, followed by less frequent services in the maintenance phase to foster patient autonomy and recovery.  Upon self-referral, the patient had a reassuring risk assessment.  She was not using alcohol or substances.  Although relations were strained largely by cultural factors, she resided with family and had a boyfriend.  She was taking college classes and was future oriented.  Following the intake appointment, she was offered individual therapy and group therapy.  She cancelled her follow-up appointment, and did not show for another appointment.  Per the medical records, mental health therapy/care once per week is not medically necessary for the treatment of this patient. Additionally, there is no evidence that the patient is enduring a psychiatric illness burden at this time requiring mental health therapy/care at a frequency of more than once a month.  All told, the requested services are not medically indicated for the treatment of this patient. 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 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 Adcirca for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient has primary pulmonary hypertension as the wedge pressure was normal and the pulmonary artery pressure was very high. The current medical evidence supports Adcirca in this clinical setting.  Combination therapy with the addition of Adcirca is a standard of care in this patients case.  All told, the requested medication Adcirca is medically indicated for the treatment of this patient. 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 pulmonary disease 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 in home physical therapy services 2-3 times per week for treatment of her medical condition status post back surgery.  Findings:  The physician reviewer found that there is a lack of recent health care provider notes to support the medical necessity of the requested in home physical therapy services. Specifically, there are no clearly documented diagnoses, rationales, or goals of the requested physical therapy, which should be part of any physical therapy treatment plan. Based on the currently available documentation, the medical necessity of the requested in home physical therapy services 2-3 times per week has not been established. Final Result: The reviewer determined that the requested therapy 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested skilled nursing facility (SNF) services for treatment of her broken femur.  Findings:  The physician reviewer found that the medical records indicate SNF services are not medically necessary for treatment of this patients medical condition. The medical literature states that better outcomes for mobility and activities of daily living are associated with occupational therapy and physical therapy intensity. The documentation indicates that this patient has been receiving occupational therapy and physical therapy. There is no evidence that this patient is on complex medications, requires initiation of tube feeding, ventilator dependence, requires extensive wound care, requires complex skilled nurse teaching to the patient or caregiver, or that the patient has medical instability or an unstable medical condition. In addition, the documentation does not indicate that the patient requires daily SNF services or that the services she requires can only be performed in a SNF setting.  The patients current occupational therapy and physical therapy needs can safely and effectively be performed at a less intense level with home therapy services and with non-skilled caregivers. Thus, the SNF services were not and are not medically necessary for this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee requested residential behavioral health treatment services for treatment of the enrollees schizophrenia, paranoid type. Findings:  The physician reviewer found that the provider noted initially that the patient was psychotic, internally stimulated, agitated, and paranoid about his parent.  Subsequently, the patient did show some improvement and could have been transferred to less restrictive setting such as a residential treatment facility. Based on these facts and considering the totality of the circumstances, the residential behavioral health treatment services were initially medically necessary for treatment of this patients medical condition. A portion of the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested single stage anterior-posterior decompression and stabilization of the cervical spine for medical treatment of his neck pain and cervical spondylosis. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for surgical procedure, single stage anterior-posterior decompression and stabilization of the cervical spine has not been established. According to the medical literature, cervical discectomy and fusion is a treatment option in patients who have evidence of radicular symptoms, cervical instability, myelopathy due to degenerative, traumatic, infectious, inflammatory and/or oncological processes, and/or failure of previous fusion as verified by diagnostic imaging that is associated with severe pain, motor deficits, reflex changes and neuropathy that results in significant functional limitations that persists despite 6 to 12 weeks of conservative treatment. Additionally, the medical literature states that surgical fusion may be recommended in patients who have failed a reasonable trial of conservative management or in patients who have incapacitating pain or progressive neurological deficits. The authors further indicate that non-operative treatment should consist of a nonsteroidal anti-inflammatory medication, immobilization, traction, physical therapy, and steroid injections. In this case, there is lack of evidence that the patient has subjective physical findings of radiculopathy. Additionally, there is no evidence of significant spinal pathology on imaging study that would support the medical necessity for surgical intervention such as evidence of severe foraminal or central canal stenosis or severe instability. Furthermore, there is lack of evidence that the patient exhausted conservative treatment. For the reasons provided, the request for surgical procedure, single stage anterior-posterior decompression and stabilization of the cervical spine is not medically necessary.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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested 3D breast tomosynthesis for medical evaluation of her fibrocystic breast disease.   Findings:  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of very dense breast tissue where the utility of standard digital mammography alone is limited due to breast density. For these reasons, the use of digital breast tomosynthesis in this patient performed was likely to have been more beneficial than standard screening mammography alone.Final Result: Three reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  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 U.S. FDA approved antiviral therapy regardless of fibrosis score. Therefore, based upon this approval supported by large clinical trials listed below, Harvoni should be approved in this patient as she already had fibrosis and Harvoni would help to prevent further progression of cirrhosis to decompensated state, and its potential complications. Thus, the requested Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus. Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for treatment of his chronic hepatitis C virus genotype 6. 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, regardless of fibrosis, should be treated except those with a limited life expectancy due to non-liver-related comorbid conditions. For treatment naive patients with genotype 6 hepatitis C, the AASLD/IDSA guidelines recommend treatment with Harvoni for 12 weeks. This regimen is based on in vitro data as well as clinical trials showing 92% sustained virologic response in this patient population. 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 with sub-specialty certification in gastroenterology 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 requested fentanyl patches for treatment of his chronic pain.   Findings:  The physician reviewer found that according to the current peer-reviewed medical literature, first-line treatment for the management of mild-to-moderate pain includes the use of non-opioid analgesics. For moderate-to-severe pain, initiation of an opioid may be recommended. Additional options include the use of fentanyl patches for patients when the oral route is not a reasonable option or has failed. In addition, the data also indicates that the recommended opioid dosage is less than or equal to a certain morphine equivalent dose. According to the clinical records submitted for review, the patient is currently taking two opioid pain medications and fentanyl patches. The patient exceeds the morphine equivalent dose recommendation. Further, the clinical records lack documentation that the patient has previously tried and failed all first-line treatments, that oral medications are not a reasonable option for this patient, or evidence of any objective functional improvement from the use of fentanyl patches. Given these findings, the requested fentanyl patches are not medically necessary for treatment of this patients chronic pain. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested a gastrointestinal (GI) tract wireless capsule endoscopy for medical evaluation of her abdominal pain, diarrhea, nausea, and vomiting.  Findings:  Two physician reviewers found that the accepted indications for capsule endoscopy include obscure GI bleeding, small bowel Crohns disease, assessment of celiac disease, screening and surveillance for polyps in familial polyposis syndromes. The medical guidelines noted that the wireless capsule endoscopy can be used in evaluation of the small bowel for tumors such as lymphoma, carcinomas or carcinoids. This patient meets none of these indications. For these reasons, the requested GI tract wireless capsule endoscopy is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested diagnostic procedure is 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 internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her osteoporosis.   The physician reviewer found that the current medical evidence supports the medication at issue in this clinical setting.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Fractures can lead to acute and chronic pain as well as increased mortality.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  Newer treatment agents have become available over the past few years, including Forteo.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bones.  Recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients.  Forteo is indicated for the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, multiple risk factors for fracture, or patients who have failed or are intolerant to other available osteoporosis therapy.  Because this patient has sustained multiple fractures while on bisphosphonate therapy, Forteo was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 a cooling device (cooling pad with pump) for treatment of her medical condition. Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the device at issue in this patients case.  Kraeutler and colleagues compared the effectiveness of compressive cryotherapy versus ice on postoperative pain in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression.  The authors noted that there did not appear to be a significant benefit to use of compressive cryotherapy units over standard ice wraps.  There is no indication that the patient would have greater benefit from a compressive cryotherapy unit versus traditional ice packs and bandaging.  All told, the superior effectiveness of a cooling device (cooling pad with pump) has not been established.  Final Result: Two 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 reviewers are board certified in orthopedic 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.