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

Nature of Statutory Criteria/Case Summary: A 69-year-old male enrollee has requested authorization and coverage for Veltassa 16.8 gram powder pack for treatment of the enrollees stage V chronic kidney disease. Fulfills requirements of (1374.33) (h)(1)(A), (B), and (C).Findings:  The physician reviewer found that Nature of Statutory Criteria/Case Summary: Based on this patients records and the available medical literature, the requested Veltassa is supported as medically necessary for treatment of this patients stage V chronic kidney disease, hyperkalemia, and metabolic acidosis. Veltassa is U.S. Food and Drug Administration (FDA) approved for chronic lowering of potassium (Bakris, et al; Bushinsky, et al). Without this agent, the provider will also have to adjust the patients anti-hypertensive medications and the patient will be on intermittent dosing with other agents to lower his potassium. Thus, the requested Veltassa 16.8 gram powder pack is medically necessary for treatment of this patients medical condition. Fulfills requirements of (1374.33)(h)(1)(H) and (K). 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. Fulfills requirement of 1374.33(h)(1)(I). Credentials/Qualifications: The reviewer is board certified in nephrology 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. Fulfills requirement of (1374.33)(h)(1)(G)
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 58-year-old female enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility level of care for treatment of the enrollee, who has been diagnosed with stage 4 renal cancer metastatic to the lungs. Fulfills Findings:  The physician reviewer found that This patient has metastatic neoplastic disease but has recently been documented to be independent with self-care and mobility.  She   She experiences fatigue and may potentially benefit from caregiver supervision or assistance at an unskilled level, but there are no indications she has ongoing skilled therapy needs requiring inpatient level care. There are otherwise no documented nursing or medical issues requiring institutional level care.  Her skin is intact.  Her pain and neuropathy have been controlled with analgesics/adjunctive agents.  She has diabetes, but this is not a new condition. Blood sugar checks and potential insulin dosing changes do not necessarily require inpatient care.  There are no indications that she has had fluctuations or issues in her sugar levels or management that preclude community-based care. She has mild, stable anemia and stable, unremarkable laboratory test results otherwise. In sum, there are no indications in the available records that she had any skilled therapy, nursing or medical needs requiring ongoing inpatient hospital level care .  All told, skilled nursing facility level of care forward was not and is not medically necessary 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 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: A 63-year-old male enrollee has requested reimbursement and prospective authorization and coverage for residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. The patients post acute withdrawal symptoms were not severe in nature. The records did not reflect that he had emotional, behavioral, cognitive, or impulsive symptoms that would have warranted this level of care.  The records noted that he was medically and psychiatrically stable. Moreover, his medication management and anti-craving medications could have been monitored in an ambulatory setting. The patient had a sponsor.  The records did not show evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care.  He was motivated and appeared to be working the program.  He and his wife were in family therapy.  He was cooperative and participating in his treatment plan.   Although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. He could have been stepped down to an ambulatory level of care such as intensive outpatient program.  The patients records did not support or meet the clinical guidelines for residential level of care. For the reasons stated above, residential treatment services provided forward were not and are not medically necessary for 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 psychiatry with sub-specialty certification in addiction 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: The parent of a seven-year-old male enrollee has requested reimbursement and prospective authorization and coverage for 20 hours per week of applied behavioral analysis (ABA) therapy and three hours per week of oversight/supervision for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that The requested 20 hours per week of ABA therapy and three hours per week of oversight/supervision provided from  were not and are not medically necessary for this patient. According to the documentation submitted for review, the patient has been documented as making progress with ABA therapy, and the records do not demonstrate a medical indication for 20 hours per week of ABA therapy and three hours per week of oversight/supervision. The Health Plans authorization of 15 hours per week of direct ABA services and two hours per week of oversight/supervision is medically reasonable and appropriate in this clinical setting. 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 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 authorization and coverage for bronchial thermoplasty for treatment of the enrollees severe persistent asthma.  Findings:  The physician reviewer found that There is data supporting the benefits of bronchial thermoplasty for selected patients. In this patients case, his asthma symptoms are atypical, being strictly exertional dyspnea and without otherwise having a demonstrable trigger. Per the records, his methacholine is positive, and the immunoglobulin E (IgE) level and exhaled nitric oxide levels are elevated, pointing to some manner of allergic disease. This may account for his dyspnea. The documentation indicated that the patient was started on Xolair. However, the medical records do not reflect the effects of Xolair. Additionally, the records do not document follow-up with an allergist and possibly starting immunotherapy. Until these are documented as attempted and unsuccessful, there is not a role for bronchial thermoplasty at this time.  In sum, bronchial thermoplasty is not likely to be more effective than other treatment modalities in this patients case. Final Result: Two of three reviewers determined that the requested services are 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested reimbursement for the gene testing (Foundation One) for evaluation of the enrollees oligodendroglioma.  Findings:  The physician reviewer found that Foundation One testing offers a comprehensive panel of molecular genetic markers on an individuals tumor with the hopes of identifying markers than can help guide therapy decision making. The National Comprehensive Cancer Network (NCCN) guidelines have not determined that molecular markers are useful in treatment determination (predictive markers) and prognosis other than codeletion of 1p and 19q, isocitrate dehydrogenase 1 and 2 (IDH1 and IDH2) mutation, and MGMT promoter methylation. There is currently a phase II clinical trial underway that is evaluating the efficacy of genetic molecular testing to guide individual therapy. In this clinical setting, testing that included codeletion of 1p and 19q, IDH1 and IDH2 mutation and MGMT promoter methylation was indicated for this patient. Thus, a portion of the gene testing (Foundation One) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two of three reviewers determined that a portion of 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 partially overturned. Credentials/Qualifications: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in medical oncology 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in medical oncology 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 reimbursement for services, specifically the use of a real time heart monitor for evaluation of the enrollee who presented with premature ventricular contractions. Findings:  The physician reviewers found that the documentation provided does not support the superior efficacy of the services at issue in this clinical setting. The records provided indicate that this patient had intermittent palpitations.  In this circumstance, if additional evaluation for a dysrhythmia is thought to be necessary then prolonged serial 48 hour Holter monitoring or off line self activated or auto triggered cardiac event monitoring should be sufficient in recording cardiac rhythm during symptoms. In this patients case, the documentation did not indicate that these devices have already been tried and failed for the evaluation of his current symptoms. Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient activated or auto triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias. Continuous real time monitoring by telemetry services is not likely to be superior since off line analysis of a patient activated or auto triggered event recorder should be sufficient in the identification of dysrhythmias during symptoms without jeopardizing patient safety. Immediate recognition and reporting of dysrhythmias through a call center provided by real time mobile telemetry services had exceeded what was clinically indicated in this patient. As such, the real time heart monitor was not likely to be more effective than the standard monitoring techniques for the evaluation of this patients medical condition. Final Result: Two of three 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and 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: A 60-year-old male enrollee has requested authorization and coverage for acute inpatient physical rehabilitation for treatment of the enrollee, who is status post right cranioplasty for right skull defect following craniectomy for infection. Fulfills Findings:  The physician reviewer found that the records indicate that the patient has a history of glioblastoma multiforme. He had undergone multiple surgeries and had undergone extensive treatment, including multiple episodes of rehabilitation. The patient was near his baseline level of function prior to the surgery. Physical therapy noted that he was performing squat pivot transfers with minimum assistance. He was ambulating with a hemi-walker with contact guard assistance to minimum assistance, up to 30 feet.  Physical therapy notes reported that the patient had reached his maximum potential.  He was requiring assistance from family for his activities of daily living.  In the hospital after surgery, he was ambulating up to 15 feet at a time with minimum assistance.  He was transferring with minimum assistance.  This was essentially at the level he was at before surgery and when his therapist had indicated that he had reached maximum potential for progression. Acute inpatient physical rehabilitation is not medically necessary as treatment could be provided at a less intensive setting of care.  All told, acute inpatient physical rehabilitation is not medically necessary 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 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: A 38-year-old female enrollee has requested authorization and coverage for a computed tomography (CT) scan and magnetic resonance imaging (MRI) for evaluation of the enrollees paroxysmal positional vertigo.  Findings:  The physician reviewer found that The documentation submitted for review does not support a medical indication for the requested diagnostic procedures. There is a lack of support in the peer-reviewed literature supporting the requested diagnostic procedures in this clinical setting. The medical records submitted for review do not demonstrate evidence of severe headaches, cluster headaches, trauma, seizure, fever, vision changes, and abnormal pressure in the head or an abnormal neurological exam. Thus, the medical necessity of either the CT scan or MRI of the brain is not clinically indicated. As such, the request for CT scan and MRI are not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures 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 diagnostic radiology 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 of Epclusa for 12 weeks for treatment of the enrollees hepatitis C virus.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, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Final Result: The reviewer determined that the requested medication regimen 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: A male enrollee has requested authorization and coverage for anastrozole for treatment of the enrollees low testosterone and elevated estradiol levels. Findings:  The physician reviewer found that this patient presents with low testosterone levels, elevated estradiol and hypogonadal symptoms due to secondary hypogonadism. Conventional treatment with testosterone replacement will further diminish his ability to produce endogenous testosterone and sperm, resulting in infertility and dependency on this hormone to maintain the benefits of normal levels therapy. Anastrozole has been used in male hypogonadism based on studies available in the peer-reviewed medical literature. Studies have shown that anastrozole is effective in decreasing estradiol in male patients with hypogonadism. In addition, treatment with anastrozole has been shown to increase testosterone levels and seminal parameters in this patient population. Given this support, the requested anastrozole is medically necessary for treatment of this patients symptomatic hypogonadism, low testosterone levels and high estradiol levels. 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 endocrinology, diabetes and metabolism 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.