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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco and valium for treatment of her diabetes type 2 with diabetic neuropathy and bilateral knee osteoarthritis. The physician reviewer found that review of the submitted documentation does not support the medical necessity of the requested medications Norco and valium. Cone and colleagues describes guidelines for opioid use that entail a careful assessment of the patient, the painful condition to be treated, and the estimated level of risk of abuse based on several factors including history of abuse and current or past psychiatric disorders; design of a therapeutic regimen that includes both pharmacotherapeutic and nonpharmacologic modalities; a formal written agreement with the patient that defines treatment expectations and responsibilities; selection of an appropriate agent, including consideration of formulations designed to deter tampering and abuse; initiation of treatment at a low dosage with titration in gradual increments as needed to achieve effective analgesia; regular reassessment to watch for signs of abuse, to perform drug monitoring, and to adjust medication as needed; and established protocols for actions to be taken in case of suspected abuse. Patients at high risk with demonstrated compliance issues are not recommended for controlled substance management.  In this patients case, the submitted medical records do not demonstrate a condition of anxiety disorder for which a benzodiazepine such as valium would be recommended on an as needed basis. Benzodiazepines are not recommended on a chronic basis due to rapid habituation and tolerance development. Further, the medical records indicate that the patient has been poorly compliant, and reportedly demonstrates pain medication seeking behavior and noncompliance following her medication regimen.  As such, the submitted medical records demonstrate that opioid and benzodiazepine use presents a safety risk for this patient. For these reasons, the requested medications Norco and valium are not medically necessary for treatment of the patients medical condition. 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 neurology with sub-specialty certification in pain management 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 an additional four weeks of Harvoni for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to 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 virus are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. In treatment-naive genotype 1 patients, the guidelines recommended Harvoni for 12 weeks (Class I, Level A recommendation). This recommendation is based on randomized clinical trials. Consideration for 8-week therapy in patients with baseline viral load of less than 6 million IU/mL is based on post-hoc analysis of the ION-3 trial, resulting in an uncontrolled comparison.  The AASLD/IDSA guidelines indicate that these results are not generalizable. Based on the evidence of safety and efficacy in the published literature, and current clinical guidelines, the extension of Harvoni to 12 weeks (4 additional weeks) is considered medically necessary in this case. 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. 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 brain magnetic resonance imaging (MRI) (CPT 70551) and brain magnetic resonance angiogram (MRA) (CPT 70544) for evaluation of his medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has new onset of skin sensitivity and facial pain.  The guidelines for appropriate imaging in headache disorders suggest that MRI is preferable to computed tomography (CT), as it is better able to evaluate clinically relevant pathology, especially in the posterior fossa.  MRA is appropriate to evaluate suspected vascular lesions such as aneurysm, arteriovenous malformations or dissection.  As noted by Sudlow, imaging detected a serious abnormality in only a very small proportion (less than 0.5%) of patients without abnormal neurological signs who presented with chronic headache or migraine or tension type headache.  The authors noted that this is no greater than the proportion of completely asymptomatic individuals in whom a serious abnormality was detected on a magnetic resonance brain scan.  In this patients case, the records do not suggest a secondary cause of headache which would necessitate the requested services.  All told, the requested brain MRI and brain MRA are not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in neurology 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 mental health residential treatment services for treatment of the enrollees behavioral health condition.  The physician reviewer found that review of the submitted evidence demonstrates the patient meets American Society of Addiction Medicine (ASAM) criteria for residential level of care. The records document the patient has escalating depression, a decline in activities of daily living (ADLs) and is unable to care for himself, as evidenced by a recent 20 pound weight loss. The clinical documentation establishes the patient has a moderate level of interference with addiction recovery efforts and impaired social functioning. He currently presents with a limited desire to change, inability to control his substance abuse, high potential for relapse and poor recovery environment at home. As such, the patient meets criteria for mental health residential treatment services,  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 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 has requested acupuncture services for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The current medical evidence does not support acupuncture services in this clinical setting.  The patient underwent prior acupuncture she reported that acupuncture partially relieved pain.  However, the records do not document examination findings, such as significant reduction of range of motion, positive orthopedic findings or functional-motor-sensory deficits, which would support the necessity of acupuncture services.  All told, acupuncture services are not medically indicated for the treatment of 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 oriental medicine with sub-specialty certification in acupuncture 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 12 weeks of Harvoni for treatment of his hepatitis C.   Findings:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The requested treatment regimen is likely to prevent further progression of disease.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated, except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  All told, the requested 12 weeks of Harvoni is medically indicated for the treatment of this patient.   Final Result: Three 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. All three reviewers are 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 Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the proposed treatment regimen is considered the standard of care in this clinical setting.  The requested medications are likely to prevent further disease progression.  The current medical evidence support combination therapy with Sovaldi and ribavirin for patients with hepatitis C, genotype 3 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  All told, Sovaldi and ribavirin for 24 weeks is medically indicated for the treatment of this patient. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 12 weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 weeks of Harvoni is medically necessary for treatment of this patients hepatitis C virus infection.   Final Result:  Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  Patients with cirrhosis are considered highest priority for treatment.  For treatment-naive patients with hepatitis C, genotype 1 infection and cirrhosis, Harvoni for 12 weeks is recommended.  Based on evidence of safety and efficacy in the published literature, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: Three 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. 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 lumbar spinal fusion (63048 x 1, 22612, 22840, 22630 and 22851) for treatment of her degenerative spondylolisthesis at L4-5.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. Lumbar fusion is supported for patients with symptomatic lumbar spinal stenosis when stenosis is moderate to severe, there is clinically significant functional impairment despite at least three months of conservative medical therapy, and there is lumbar spondylolisthesis for spinal instability on imaging, or spinal instability is anticipated with surgery.  In this case, the MRI of the lumbar spine demonstrated mild central stenosis with some left lateral recess stenosis at L4-5, with moderate narrowing of the left neural foramen. It was noted that the patient had attempted Neurontin and epidural steroid injections with no pain relief. However, there was no documentation of instability on diagnostic imaging.  In addition, there was no discussion of the need for wide decompression that would result in temporary intraoperative instability. Based on the clinical documentation provided, lumbar spinal fusion (63048 x 1, 22612, 22840, 22630 and 22851) is not medically necessary for treatment of the patients medical condition. 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:   An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus genotype 1a.   Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested Viekira Pak is medically necessary for treatment of this patients hepatitis C virus infection.  Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Genotropin for treatment of the enrollees idiopathic short stature.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient has short stature and appropriate slowing of his growth velocity at the end of puberty. He has normal growth factors, a normal GH response on provocative GH testing, and no known morphological abnormalities of his pituitary gland. His bone age previously showed nearly fused epiphyses, and at this point in time, he is not expected to experience acceleration in growth velocity with GH therapy. This patient does not have GH deficiency, and his bone age is too mature to consider a trial of GH therapy for idiopathic short stature. Thus, GH is not clinically indicated. Based on the medical literature cited above and the documentation submitted for review, the request for Genotropin is not medically necessary for treatment of the 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 pediatric endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: 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.  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. This patient is also noted to have a family history of Ashkenazi Jewish descent. For these reasons, the use of digital breast tomosynthesis in this patient 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: 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.