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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested immune cell function assay lab testing for evaluation of her chronic urticarial.  Two physician reviewers found that this patients signs and symptoms are consistent with chronic urticaria. Laboratory evaluation has confirmed this diagnosis via history of autoimmune thyroid disease and evidence of thyroid antibodies. However, the patient had not been treated with standard therapy prior to this visit, thus there was no evidence of failure of primary therapy. The chronic urticaria index is a test which consists of basophil histamine release assay. At this time, the clinical utility of this test is not well established and there are currently no national guidelines recommending routine use of this test. All told, this test is not needed to make a diagnosis of chronic urticaria, guide therapy or follow for clinical disease course. Accordingly, the immune cell function assay lab testing was 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 services at issue were 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 internal medicine with sub-specialty certification in rheumatology and is actively practicing.  Two reviewers are board certified in internal medicine and allergy and immunology 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 atovaquone (Mepron) for treatment of her diagnosis of Lyme disease. The physician reviewer found that as noted by Lantos and Wormser, there is a lack of evidence of chronic Babesia infection in immunocompetent persons in the absence of fever, laboratory abnormalities and detectable parasitemia. The serological data cited as the reason for treating this patient for Babesia duncani infection is inadequate. There is no four-fold change in antibody titer, evidence reported from polymerase chain reaction (PCR) studies, or blood smears that parasitemia has been documented. In the absence of studies demonstrating the presence of chronic Babesia infection, the requested Mepron medication is not 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 infectious diseases 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 orthodontic care for treatment of the enrollees arch length discrepancy. The physician reviewer found that to qualify for orthodontic treatment, the patient must meet specific criteria on an objective scale which assesses the relative disability. In this case, the handicapping labiolingual (HLD) index was utilized. There is no clinical indication that any of the specified criteria are met due to severe handicapping situations or compromise of health. The computed score on the HLD index was 11, which is well below the accepted minimum score of 25 required to indicate a severe handicapping malocclusion. Therefore, based on the patients records and with minimal crowding of the teeth, the requested orthodontic treatment is not dentally 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 oral and maxillofacial 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 Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  For cirrhotic patients, the efficacy of Harvoni has been well-demonstrated.  By virtue of her compensated cirrhosis, this patient meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for immediate treatment with the highest priority.  However, the Health Plan has offered coverage for Viekira Pak which is equally efficacious in this setting.  As such, the medical necessity of the requested medication Harvoni for 12 weeks as opposed to the alternative Viekira Pak has not been established.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment for treatment of the enrollees bipolar disorder. Findings: The physician reviewer found that this patients records do not support the medical necessity of residential treatment center (RTC) level of care services. The patient denied suicidal and homicidal ideation. She demonstrated no self-harm behaviors and she has not been aggressive or threatening towards others. She has been independent in self-care and cognitively intact. Overall, there is a lack of evidence that the patient required the intensity and supervision provided at the RTC level of care. Given these findings, the RTC services were not and are not medically necessary for treatment of this patients medical condition. 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that the requested treatment is medically necessary and is considered the standard of care for the treatment of patients with chronic hepatitis C. In this case, the patient presents with advanced stage disease as he has progressed to cirrhosis. 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 Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has evidence of cirrhosis. Therefore, per the national guidelines Harvoni for 12 weeks is medically necessary. 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 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 methadone and Norco for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the requested medications has not been established. According to the documentation submitted for review, the patient has been treated with opioids long term without documentation of improved function or attempted weaning. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Moreover, the current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended. A study 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. For the reasons provided, the patients request for methadone and Norco is not medically necessary.Final Result: The reviewer determined that the requested medications 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 anesthesiology and 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 psychotherapy sessions for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that current practice guidelines support the use of evidence-based psychotherapies in the treatment of bipolar depression. According to the American Psychiatric Association (APA), patients who are currently in a depressive episode and are at high risk for non-adherence to medication should be considered for psychotherapeutic interventions such as cognitive behavioral therapy, family therapy, or interpersonal and social rhythm therapy. These therapies are typically delivered on a weekly basis and represent reasonable interventions aimed at improving the patients condition and preventing a more serious episode of illness. Consistent with these findings, the requested psychotherapy sessions are safe, appropriate and medically necessary for treatment of this patients medical condition.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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast. A researcher noted that breast tomosynthesis technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. Other researchers concluded that, addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested hyaluronate viscosupplementation injections for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting.  Researchers performed a meta-analysis of 137 studies with 33,243 participants and concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Another researcher 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.  This patient has been diagnosed with severe bilateral knee osteoarthritis.  She has undergone prior series of viscosupplementation injections with significant benefit documented both in terms of pain reduction and improvement in functional ability.  There is documentation that prior conservative treatment, including physical therapy and medications, have failed to provide benefit.  Therefore, the requested hyaluronate viscosupplementation injections are medically indicated for the treatment of this patient.  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: 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:  An enrollee has requested substance abuse residential treatment center level of for treatment of his behavioral health conditions.   The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patients substance use, particularly opiates, dominated his functionality and generated distress.  His substance use resulted in dismissal from a treatment program just prior to the disputed service.  The Health Plan suspended coverage due to the patients lack of motivation and poor progress.  However, insufficient motivation is reason for placement in more restrictive settings.  Thus, the setting was safe, appropriate and consistent with good medical practice.  The treatment team was actively re-assessing the most appropriate setting and ultimately determined that a change was clinically indicated.  Considering the treatment up until that time, it was reasonable to involve family in the transition plan, and this occurred.  Thus, the services in dispute were medically necessary initially, but not thereafter.  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 partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this patients case.  Direct acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America. The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis (F3) or compensated cirrhosis (F4) and those with severe extrahepatic manifestations of hepatitis C.  High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis, and those with coexisting liver disease.  The FibroSure test is recognized as an accurate predictor of fibrosis compared to histologic assessment.  All told, the requested 12-week course of Harvoni 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 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 a sleep study performed at a sleep center for evaluation of his sleep difficulties. This patient has some symptoms of obstructive sleep apnea, and testing for this condition was therefore appropriate. However, home testing would not have been adequate in this patients clinical situation. The clinical guidelines recommend home sleep studies for patients with a high pre-test probability for moderate to severe obstructive sleep apnea. In this case, the absence of witnessed apneas placed the patients pretest probability at moderate for mild obstructive sleep apnea. Home sleep studies do not provide the diagnostic sensitivity that is required in these types of cases. As a result, the sleep study performed at a sleep center was medically necessary for thorough evaluation of this patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep 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 breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, the use of 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.