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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for substance abuse treatment through intensive outpatient program (IOP) rendered on date of dispute and forward. Findings:  The physician reviewer found that although chemical dependency services are indicated, the documentation provided in this case does not support the medical necessity of continued IOP services. The patient showed significant improvement during her initial 10 sessions of IOP programming.  However, the record fails to demonstrate that less restrictive interventions, targeting her substance use during the episode of illness, would have been either unsuccessful or inappropriate.  According to the records, this patient is motivated for treatment.  She has not had any alcohol in two months or consumed any opiates in more than three months.  She has embraced treatment principles and done well during two weeks of IOP programming.  She has a temporary sponsor and is reportedly attending meetings.  She has a safe and sober residence.  Her supportive spouse of 10 years has been in recovery for nearly 20 years.  Although the patient has difficulty embracing her introverted nature and has not processed significant losses from her past, the records do not indicate that she is having an acute psychiatric syndrome. The patient is both psychiatrically and medically stable.  She has no history of suicidality.  She is prescribed the antidepressant combination of bupropion and trazodone.  Further, the documentation does not include a current treatment plan or a subsequent psychiatric evaluation indicating the clinically recommended duration of treatment.  Finally, the patient has not been involved in any previous chemical dependency care, and this is significant as treatment gains are optimized in the outpatient setting. Considering the clinical presentation and treatment history, there is no evidence to suggest that comprehensive specialty services provided in the community at the outpatient level of care would be unreasonable or inconsistent with adequate care.  Thus, the IOP services provided on date of dispute and forward were not and are not medically necessary for treatment of this patients behavioral health 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 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 total abdominal hysterectomy, possible oophorectomy for treatment of the enrollees severe vaginal bleeding. Findings:  The physician reviewer found that in choosing an alternative to hysterectomy, both safety and efficacy need to be considered for each treatment. It must be recognized that alternatives to hysterectomy allow the possibility for new leiomyomas to form, and/or for preexisting small or undetected leiomyomas to exhibit significant growth, necessitating another treatment. The risk of recurrence must be balanced against the potential benefits of uterine sparing procedures.  Contraceptive steroids are often first-line therapy for control of abnormal uterine bleeding and painful menstruation in women with and without leiomyomas. However, evidence-based reviews suggest that current medical therapies tend to give only short-term relief, and the crossover rate to surgical therapies is high.  In this case, the patient has a fibroid uterus and has failed several attempts at medical therapy. In addition, her menometrorrhagia is significant and has required several blood transfusions. The medical evidence supports the requested services in this clinical setting. 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 obstetrics and gynecology 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 Epclusa 400/100 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a pressure reducing mattress for treatment of his ankle fracture. Findings:  The physician reviewer found that a review of the literature and this patients medical documentation does not reveal that the patient meets the medical requirements for a pressure reducing mattress. There is no documentation that this patient is completely immobile or unable to make position or weight shift changes. Further, there is no evidence of a current pressure ulcer or altered sensation, impaired nutritional status, or incontinence.  Final Result: The reviewer determined that the requested device 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing care services for treatment for her history of varicose veins of left lower extremity with ulcer of unspecified site, morbid obesity, abnormal posture and muscle weakness. Findings: The physician reviewer found that that patient had made functional progress and was at or near her premorbid functional baseline of using a wheelchair and ambulating limited distances with a walker. She was continuing to require supervision to stand by assistance for most of her self-care and basic household level mobility. There was no documented evidence of planning or arrangements for community reintegration with some level of caregiver assistance or home health services.  The patient could have otherwise returned to the community with some custodial level support for supervision and basic assistance with activities of daily living. Although the medical literature generally supports subacute or skilled nursing facility level inpatient rehabilitation in a variety of clinical settings, including recovery from general medical illness such as sepsis, encephalopathy and respiratory failure, the medical literature does not support the medical necessity of this intervention indefinitely in the absence of expected functional progress. Final Result: The reviewer determined that the services at issue were 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 authorization and coverage for QNASL 80 mcg for treatment of her chronic sinusitis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Reviews comparing steroid based nasal sprays indicate that there is no difference in efficacy between them.  The differences found are in patient preference and safety during pregnancy. QNASL has not been found to be more efficacious than the Health Plans standard therapy available on the formulary. 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 otolaryngology 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 Repatha 140 mg/ml Sureclick subcutaneous every two weeks for treatment of her hyperlipidemia. Findings:  The physician reviewer found that the records document known coronary disease and persistently high LDL cholesterol despite maximally tolerated statin dose and a trial of Zetia.  Repatha is a proprotein convertase subtilisin kexin (PCSK9) inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient fits the latter criteria. Randomized clinical trials have demonstrated effective LDL lowering in this setting as well as improvement in cardiac outcome in post hoc analyses.  The medical evidence supports the requested medication in this clinical setting.  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 cardiovascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Afirma Gene Expression Classifier for evaluation of her thyroid nodule. Findings:  Three physician reviewers found that there is sufficient peer-reviewed scientific literature demonstrating the benefits of genetic testing in thyroid nodules. The American Thyroid Associations guidelines state that for nodules with AUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. In this case, the cytopathology of the thyroid nodule was consistent with AUS. The result of the Afirma was suspicious for malignancy. This information was important to determine the extent of surgery, such as a hemi-thyroidectomy versus total thyroidectomy. Without the results, a hemi-thyroidectomy would likely have been performed, but a thyroidectomy would be indicated if malignancy was found. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for prescription modafinil for treatment of the enrollees excessive daytime sleepiness. Findings: The physician reviewer found that Modafinil is U.S. Food and Drug Administration (FDA) approved for patients with excessive sleepiness associated with OSA, narcolepsy or shift work disorder. The documentation submitted for review does not support the patient has any of these diagnoses. According to the American Academy of Sleep Medicine, the diagnostic criteria for shift work disorder requires: a report of insomnia and/or excessive sleepiness, accompanied by a reduction of total sleep time, which is associated with a recurring work schedule that overlaps with the usual time for sleep; symptoms have been present and associated with the shift work schedule for at least three months; symptoms cause clinically significant distress or impairment in mental, physical, social, occupational, education, or other important areas of functioning; sleep log and actigraphy monitoring (whenever possible and preferably with concurrent measurement of light exposure) for at least 14 days (work and free days) demonstrate a disturbed sleep and wake pattern; and sleep and/or wake disturbance are not better explained by another current sleep disorder, medical or neurologic disorder, mental disorder, medication use, poor sleep hygiene, or substance use disorder. In this case, the patients work schedule does not lead to a reduction in total sleep time as she is noted to get 8.0 to 8.5 hours of sleep during the week. Her work schedule does not readily overlap with the usual time for sleep. It is also not clear that the excessive daytime sleepiness is not due to other causes such as poor sleep hygiene, particularly on the weekends. There is also no documentation of a disturbed sleep pattern via sleep logs to help evaluate the patients condition as required by current diagnostic criteria. Although the provider states that the patient may have a circadian rhythm disorder, current practice guidelines do not endorse the use of pharmacotherapy in such conditions. In sum, the records provided for review fail to establish a diagnosis of shift work disorder based on current diagnostic criteria. 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 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: A 60-year-old male enrollee has requested reimbursement for the percutaneous kyphoplasty for treatment of his severe back pain. Findings:  Two physician reviewers found that traditional open surgery has numerous complications, and radiation therapy may take weeks to become effective. To avoid the trauma and complication of open surgery, percutaneous kyphoplasty (PKP) is a minimally invasive procedure that has played a great role in the treatment of spinal metastases over the past several years. Researchers found that as a minimally invasive procedure, PKP may not only rapidly relieve the pain and disability experienced by patients, but it may also restore the kyphotic angle observed at the one-year follow-up. Notably, PKP may safely improve the quality of life of patients. Researchers reported that balloon kyphoplasty is a minimally invasive procedure that provides immediate and long-term pain relief and improvement in functional ability in selected patients with metastatic vertebral compression fractures. The procedure appears to have good long-term safety. Similarly, other research provided support for the procedure stating that kyphoplasty is a safe and effective procedure for treating painful vertebral body fractures caused by metastasis and multiple myeloma. It can restore vertebral body height and correct the kyphosis angle. Thus, the literature does support the use of kyphoplasty to provide pain relief and improve the functional capacity of patients with painful or unstable metastatic vertebral compression fractures. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for buprenorphine HCL 8 mg for treatment of the enrollee who has a history of ankylosing spondylitis. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity of the requested buprenorphine in this clinical setting. The records do not mention counseling, despite research and recommendations to support its use in opioid dependency and abuse. It is unclear what the plan is for this patient since the notes state she is taking Nucynta and buprenorphine. Moreover, there is no clear objective functional goals for the additional buprenorphine being requested. Buprenorphine is only U.S. Food and Drug administration approved and indicated for opioid dependence. However, this patient does not acknowledge she has an opioid dependency. The patient does not state she is taking the medication to be free from opioids but rather she is requesting the medication for pain control. Furthermore, per the provider, Suboxone was effective therapy for this patient. As such, given the patient has a history, Suboxone should be sufficient. It is unclear why this patient believes Suboxone will be problematic due to future surgeries. Finally, multiple minimal requirements for opioid prescribing have not been performed. The need to use buprenorphine alone or alongside another opioid for an indefinite basis as the primary medication treatment strategy for pain or opioid dependency has not been established. Final Result: The reviewer determined that the requested medication was not and 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-certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP)Findings:  The physician reviewer found that  he documentation submitted does not support the medical necessity for the services at issue. The patient denied suicidality or homicidality, and she was not manic or psychotic.  She demonstrated motivation, and progress notes show steady progress in treatment evidenced by the decline in purging.    She showed the ability to go for extended periods without eating disorder behavior. The records documented that she was compliant, and recognized her triggers and the need to reach out for help.  She lived in an emotionally supportive environment. She was 122 pounds, which was close to her goal weight of 124.4.  At this point, she did not require the structure of partial hospitalization, and could have stepped down to a lower level of care. Final Result: The reviewer determined that the services at were 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.