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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested continuation of frequency of direct applied behavioral analysis (ABA) therapy and supervision for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Orinstein and colleagues found that children with optimal outcome from the ASD started ABA at an earlier age of 4-5 and were receiving 25 hours per week of therapy compared with 18 hours per week for those with high functioning autism. ABA services are medically indicated for treatment of the patients autism spectrum disorder. The patient has received high level ABA since 2012 which have been effective for some skills including communication, executive functions and adaptive skills. However, he continues to have elopement issues and frequent stereotypy. A significant decrease in ABA services often leads to a return of previously addressed maladaptive behaviors and slowing of progress. Therefore, a portion of the per week requested direct ABA and supervision is medically necessary for this patient.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 Pura-ply for treatment of the enrollees venous stasis ulceration.  Findings: Three physician reviewers found that there is a lack of support for the product at issue in this patients case.  Pura-ply is a dermal substitute which has been approved by the U.S. Food and Drug Administration (FDA) for acute and chronic wound management across a variety of wound types, including partial-thickness and full-thickness wounds, pressure ulcers, surgical wounds, trauma wounds, and venous and diabetic ulcers.  However, there is a lack of long-term, prospective clinical trials which have demonstrated superior outcomes and efficacy compared to existing wound care therapies.  A review of the medical literature indicates that the few clinical trials which have been performed using this product tend to be short-term, industry sponsored and of small sample size.  Thus, there is insufficient clinical evidence to support its use as superior to existing therapies for this patient.  In sum, the superior efficacy of Pura-ply provided has not been established.Final Result: Three reviewers determined that the product at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should 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 (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested non-emergent transportation services to and from appointments for treatment of the enrollee, who has been diagnosed with neovascular age-related macular degeneration.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient requires frequent injections.  The patients vision is not clear enough, especially after the injections, to drive herself home after the appointments, or to take public transportation alone.  If she does not have someone to give her a ride or accompany her on public transportation, non-emergent transportation is the only viable option for this patient.  Thus, the requested services are needed to allow the patient to receive necessary medical treatment.  All told, the requested non-emergent transportation services to and from appointments with the Health Plans ophthalmology department 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: Physician reviewer is board certified in ophthalmology 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 90-400 mg tablets for treatment of the enrollees 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should 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 (Kowdley, et al; Afdhal, et al). Although Viekira Pak is also recommended, it is contraindicated in this case due to major drug interaction with estradiol, which is noted to be taken by the patient. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for speech therapy at the frequency of three one-hour sessions per week for treatment of the enrollees expressive and receptive language disorder. Findings:  The physician reviewer found that in this case, the patient presents with severe receptive and expressive language disorder and significant oral motor problems. The recommendation for three one-hour sessions of speech therapy per week is clinically indicated for this patient. The medical literature supports higher treatment intensity of speech therapy. For the reasons stated, speech therapy at the frequency of three one-hour sessions per week are medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 digital breast tomosynthesis for evaluation of the enrollees risk of breast cancer. Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breast tissue described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the digital 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 service 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.  Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantage to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Ciatto and colleagues investigated the effect of integrated two-dimensional (2D) and three-dimensional (3D) mammography in the breast cancer screening population. The authors found that Integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. Based on the medical literature cited above, 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: Three reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400 mg tablets for 12 weeks for treatment of the enrollees 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 should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should 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. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg daily for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a four-year-old enrollee has requested admittance into a childrens hospital intensive multidisciplinary feeding program for treatment of the enrollees feeding problems. Findings: The physician reviewer found that this patient is gastrostomy tube dependent and has been in outpatient therapy without much progression. He has not shown a failure to thrive and does not have electrolyte abnormalities but this is because he is getting gastrostomy tube feeds. The patient is no longer progressing in outpatient therapy, so inpatient therapy may be able to get him to take foods by mouth as well as accept a larger variety of foods. The goal is to stop his gastrostomy tube, and inpatient feeding programs have been shown to be more effective than outpatient therapy sessions. All told, the requested admittance into a childrens hospital intensive multidisciplinary feeding program is supported as medically necessary for treatment of this patients feeding problems.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 pediatrics and pediatric 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 substance abuse residential services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity for the services at issue. In a first noted psychiatric the reviewer found that the patient continued to have insomnia and depression, no new psychiatric medication changes were made, and she denied any suicidal or homicidal ideations. There was no evidence of psychosis noted. She continued to have poor insight and judgment. In a subsequent psychiatric evaluation two days following the first, it was noted that she had a good week, she was not having any issues with sleep and her medication seemed to be helping her cope with her stressors. She denied any suicidal or homicidal ideations again. The medications appeared to be helping her. There was no evidence of suicidal or homicidal ideation, no evidence of psychosis, and both insight and judgment were deemed fair. In the psychiatric evaluation dated three weeks later, similar symptoms and planning were shown.  All told, the documentation provided does not demonstrate that the patient required the structured 24-hour setting of a residential treatment center after the second noted psychiatric evaluation.  The patient could reasonably have been treated at a lower level of care in an outpatient care. Therefore, for these reasons, the services following the second noted psychiatric evaluation were not medically necessary for treatment of this patient.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 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 tip rhinoplasty for treatment of the enrollees nasal deformity. Findings: The physician reviewer found that the tip rhinoplasty has not been established as medically necessary or reconstructive in nature for treatment of the patients medical condition. Based on the documentation provided, the rhinoplasty did not address the patients partial nasal obstruction. Cephalic trim and dorsal hump resection are consistent with cosmetic intervention, as well as the lateral osteotomies. Typical interventions for reconstructive principles include, but are not limited to spreader grafts, septoplasty, turbinectomy and other grafts. On previous evaluation, the initial provider had documented evidence of traditional findings associated with nasal airway obstruction, including septal deviation and large turbinates. Turbinectomy and septoplasty were not contained in the operative note. Although, the patient had a functional deficit possibly related to her septum and enlarged turbinates, the procedure did not address these concerns. In sum, the patient had functional impairment that could have been addressed with surgical intervention, but the tip rhinoplasty did not address the patients functional impairment. In addition, the patient did not have a significantly abnormal appearance based on the photographs and medical documentation submitted for review. The patients appearance was relatively normal and the surgical intervention performed was to improve the patients appearance.Final Result: The reviewer determined that the surgery at issue was not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic 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.