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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Vest chest wall oscillation device for treatment of her bronchiectasis. The physician reviewer found that as every patient with pneumonia has a local bronchiectastic reaction in the area of pneumonia, there is a lack of documentation that diffuse bronchiectasis is this patients primary lung disease. However, even if this patient has diffuse bronchiectasis, the Vest chest wall oscillation device would not be medically necessary. The Vest Airway Clearance System (Vest) is a high frequency chest wall device for chest physical therapy and has been available since 1988. The device has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is considered the standard of care. However, there has been no documented superiority of the Vest over routine chest physical therapy in any disease entity where the long-term endpoint of the prospective clinical trial were clinically significant outcome endpoints such as fewer hospitalizations for pulmonary infections, decrease in length of stay of a hospitalization, or decrease in the progression of pulmonary disease. All told, the Vest chest wall oscillation device was not and is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the device at issue 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 internal medicine and 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with worsening swelling and throbbing of a left hand laceration that occurred the day before. The physical exam was significant for tenderness of the left palmar laceration and the patient was noted to be in an extensive amount of pain. Given the patients severe pain and the possibility of serious deterioration and compromise of her hand due to infection that could spread to nearby vital structures such as joints, nerves and tendons, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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 a new power wheelchair and accessories for treatment of her cerebral palsy spastic quadriplegia. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested equipment. According to the documentation submitted for review, a new power wheelchair is indicated given that her current chair is in disrepair. However, the requested power wheelchair (Permobil F5 Corpus - K0884) is not medically necessary. The Permobil F5 is group 4 standard power wheelchair with power elevating seat and standing feature. In this clinical setting standard group 3 power wheelchair would be sufficient to meet the patients wheelchair needs. Based on the clinical documentation submitted, a new power wheelchair and accessories are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for evaluation of her thyroid nodule. Three physician reviewers found that the Afirma fine needle aspiration analysis was likely to be more effective for this patient than other available treatment options. The medical literature supports the services at issue in this clinical setting. Approximately 15 to 30% of thyroid nodules evaluated by means of fine-needle aspiration are not clearly benign or malignant. Patients with cytologically indeterminate nodules are often referred for diagnostic surgery, though most of these nodules prove to be benign.   According to McIver and colleagues The Afirma GEC demonstrates a lower than expected rate of benign reports in follicular or Hurthle cell neoplasm and a lower than anticipated malignancy rate within GEC-suspicious nodules. Therefore, the genetic testing was clinically indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in medical oncology and is actively practicing.  Two reviewers are board certified in endocrinology and metabolism 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested saline injections into a perforator vein for treatment of her bilateral lower extremity swelling. Three physician reviewers found that review of the submitted documentation and relevant literature fails to support the services at issue in this clinical setting. There is a lack of documentation demonstrating ulceration resistant to compression therapy. In addition, there is a lack of documentation showing absence of deep venous obstruction. There is also no documentation of significant reflux in the vein treated and no evidence that associated major superficial vein reflux is absent or has been treated. The size of the vein is also not documented nor is the concentration of saline as it is reported that the hypertonic saline was diluted. For the reasons provided, the documentation submitted for review does not support the services at issue as likely to be more beneficial than other modalities for the treatment of the patients medical condition.  Final Result: The reviewer 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 thoracic surgery with sub-specialty certification in vascular surgery and is actively practicing. Two reviewers are board certified in vascular 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Otezla for treatment of his psoriasis. The physician reviewer found that the request for Otezla is not medically necessary in this clinical setting. The patient is requesting coverage for Otezla (apremilast) for treatment of psoriasis affecting greater than 30% body surface area. This patient is an appropriate candidate for systemic therapy to control his chronic plaque psoriasis. However, there are several options available including injectable biologic such as etanercept or adalimumab. It would be medically appropriate and safe for the patient to try one of the injectable medications to treat his disease.  In addition, there is a lack of documentation demonstrating contraindications or intolerance to other medications such as etanercept or adalimumab. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla 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 dermatology 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 chronic hepatitis C virus genotype 1a.   Findings:  The physician reviewer 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. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. 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 treatment with Harvoni for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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 Rozerem 8 mg, three tablets at bedtime, for treatment of his insomnia. The physician reviewer found that per the medical evidence, patients with insomnia should receive therapy for any psychiatric illness, medical condition, substance abuse, or sleep disorder that may be precipitating or exacerbating the insomnia.  For patients with continued symptoms which require intervention, cognitive behavioral therapy is the initial therapy that is recommended.  If a patient requires a combination of behavioral therapy and medication, a short-acting medication is recommended for six to eight weeks and then tapered.  If symptoms continue, an evaluation in a sleep disorder center prior to the institution of long-term medications is appropriate.  Rozerem is a hypnotic medication that is a melatonin receptor agonist, and the FDA has approved the dosage of Rozerem 8 mg to be taken within 30 minutes of bedtime.  It is approved for treatment of insomnia characterized by difficulty with sleep onset.  In this case, the documentation notes that Rozerem 8 mg is not an effective dose for this patients insomnia.  There is no documentation available to show that the patient has received sufficient treatment for any medical or psychiatric conditions contributing to his insomnia.  Additionally, the records do not document medical reasons why this patient should receive a non-FDA approved dose of Rozerem for insomnia.  All told, Rozerem 8 mg, three tablets at bedtime is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to the screening examination has gained worldwide acceptance due to the associated decrease in callbacks and increase in the detection of small cancers.  Per the medical literature, the addition of breast tomosynthesis to digital mammography was likely to have been of greater benefit to the patient than digital mammography alone.  All told, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  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 Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as 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. 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 is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   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 Cialis once daily for treatment of his medical condition. .  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The patient has a diagnosis of erectile dysfunction.  Per the medical records, he has had prior treatment with Levitra and Viagra.  The patient has requested coverage for Cialis once daily, although the Health Plan limits coverage to six per month.  Cialis once daily is an option for treatment of men with erectile dysfunction.  However, the current medical literature does not support improved efficacy with use of daily Cialis in patients who are responding adequately to as needed Cialis therapy.  Additionally, the diagnosis of benign prostatic hypertrophy is not documented.  There is no documentation of lower urinary tract symptoms, physical examination and diagnostic studies suggesting benign prostatic hypertrophy.  Studies comparing alpha blockers and daily Cialis used a monotherapy have failed to prove superiority of daily Cialis over alpha blocker therapy.  All told, Cialis daily is not medically indicated for the treatment of this patient. 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 urology 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 corrective hip surgery for treatment of his medical condition.  The physician reviewer found that the peer-reviewed literature supports revision total hip arthroplasty as useful to address femoral offset restoration and leg length equalization in patients with functional limitations when a surgically correctable cause of limb-length discrepancy can be identified.  Forster-Horvath and colleagues concluded that there was no universal definition of leg length discrepancy after total hip replacement, but there was a consensus that less than 10 mm was acceptable.  The authors found that the underlying cause was femoral component malpositioning in the vast majority of cases which led to significant limping, lower back pain and nerve palsy.  The authors recommended that revision surgery without knowing the underlying pathology should be avoided.  In this case, the patient reported daily left lateral hip and thigh pain radiating to the knee.  Clinical examination findings were consistent with iliotibial band syndrome and the provider opined this was likely secondary to leg length discrepancy.  The radiographs demonstrated at least 5 mm of leg length discrepancy and evidence of increased offset. There was no evidence of hardware loosening, malposition, or infection.  Detailed evidence of a reasonable and comprehensive less invasive treatment trial, for example shoe lift correction trial and failure, has not been submitted.  Significant improvement in strength and muscle activation was reported with recent physical therapy with ongoing treatment noted.  All told, the requested corrective hip surgery is 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure rupture of membranes (ROM) test for evaluation of her contractions with fluid leakage. Two physician reviewers found that according to the American College of Obstetricians and Gynecologists (ACOG), AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid when these tests are inconclusive. AmniSure is not recommended as a first-line test. One prospective study has found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes and a second study reported it to be highly accurate in diagnosing fetal membrane rupture. However, other studies have noted false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. This patient did not have inconclusive standard testing before the AmniSure test since both ferning and nitrazine were negative. Thus, the AmniSure ROM test 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 evaluation 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 obstetrics and gynecology 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.