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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100mg-40mg, three times daily, for eight weeks. The submitted documentation supports the medical necessity of the requested medication regimen. 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret 100mg-40mg, three times daily, for eight weeks. Zeuzem and colleagues reported that the ENDURANCE-1 trial showed that only 8 weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100mg-40mg, three times daily, for eight weeks is medically necessary for this patient.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 a subspecialty 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

An enrollee has requested reimbursement for neuropsychological testing. Neuropsychological testing is a form of testing that is used to determine neurocognitive implications of medical or neurological diseases. Testing is performed by a neuropsychologist and examines cortical dysfunction, specifically analyzing deficits in attention, memory, processing, language, motor function and intelligence. This patient underwent neuropsychological testing for depressive disorder, anxiety, and lapses in attention. There is a lack of evidence to support this testing with regards to anxiety and depression. Per the records, her complaints were due to an underlying psychiatric process where neuropsychological testing is not indicated. Therefore, neuropsychological testing was not medically necessary for the evaluation of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center services. The submitted documentation supports the necessity of the patients residential treatment center stay. The patient has a long history of alcohol use disorder with a recent relapse noted as a four-day drinking binge, which resulted in a visit to the emergency room. The patient was admitted for detoxification and withdrawal management services, and they subsequently started treatment at a residential treatment center. On the day prior to the period in issue, the patients Addiction Severity Index-Lite (ASI-Lite) Summary noted that the patient discussed having a plan to commit suicide and had made two attempts in the past. On the last day of the period in issue, the patients discharge summary noted that the patient reported passive suicidal ideation without an active plan. The patient denied any acute suicidal ideations and was deemed stable for discharge and was negative for alcohol withdrawal symptoms. The residential treatment center stay during the period in issue was medically necessary for the stabilization of the patients psychiatric symptoms, including their recent relapse of alcohol use, which could have been life threatening. Accordingly, all of the residential treatment center services provided during the period in issue were medically necessary to treat the patients condition.Final Result: The reviewer determined that the services in issue were medically necessary for treatment of the patients medical condition. Therefore, the patient should be reimbursed for the services in issue, and the Health Plans denial should be overturned.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: The parent of an enrollee has requested authorization and coverage for speech therapy. Researchers stated that `[c]hildren with autism benefit from intensive, early intervention that focuses on increasing the frequency, form, and function of communicative acts. Available evidence shows that highly structured behavioral methods have important positive consequences for these children, particularly in eliciting first words.` Researchers review the importance of early intervention (less than 3 years) for children with autism spectrum disorder, emphasizing that developmental and behavioral approaches often underlie the therapeutic strategies employed by speech and language pathologists. Researchers concluded that behavioral-based interventions were evidence-based to introduce speech to non-verbal individuals with developmental disabilities. Researchers describe that treatment of individuals with autism spectrum disorder involves intensive behavioral therapy and educational programming along with traditional ancillary services, such as speech/language, occupational, and physical therapies.In this case, there was positive change between the skill level of the enrollee on the speech and language evaluation performed initially and that performed subsequently. The letter by the speech therapist who had been treating the enrollee clearly indicates that the enrollee is making progress with, and benefitting from, individual speech therapy. The requested authorization and coverage for speech therapy is therefore medically necessary for treatment of the enrollees medical condition (autism spectrum disorder).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 board certified neurologist with a special qualification in child neurology. 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 Privigen 500 mg IVIG therapy. The submitted documentation supports the medical necessity of the requested treatment. BK viremia is associated with poorer outcomes with renal allografts. The risks of allograft failure are great. IVIG therapy is considered standard of care for this particular condition and has been shown to be effective. Options for this patient are limited, and the consequences of failed therapy are severe. Under these circumstances, IVIG therapy is not only indicated, but would be considered standard of care. Accordingly, Privigen 500 mg IVIG therapy is medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested treatment 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 subspecialty certification 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mekinist (trametinib) 0.5 mg tablets. The submitted documentation supports the medical necessity of the requested medication. Approximately 50 percent of cases of Erdheim-Chester disease (ECD) do not harbor a BRAF mutation, but will have NRAS, PIK3CA, or mutations of the RAS-PI3K-AKT signaling pathway, providing rationale for targeting other components of this pathway aside from BRAF. Treatment with a MEK inhibitor, such as Trametinib, is recommended for patients without a BRAF mutation and who have mutations that suggest a response to a MEK inhibitor, such as KRAS. In this case, testing has revealed that the patient has a KRAS mutation. Under these circumstances, where there is no standard of care for this rare disorder, and there is data to support the use of trametinib for a BRAF negative patient with ECD, Mekinist (trametinib) 0.5 mg tablets are medically necessary for treatment of the patients medical condition.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 subspecialty certifications in medical oncology and hematology, 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

enrollee has requested authorization and coverage for a referral to a nephrologist. Per the Kidney Disease Improving Global Outcomes (KDIGO) Guidelines, referral to a nephrology specialist is indicated when:1. There is acute renal insufficiency (stage 4/5) or abrupt fall in GFR (GFR < 30);2. There is consistent finding of significant albuminuria;3. Progression of chronic kidney disease (CKD)  GFR decline > 25% from baseline;4. Blood in urine not easily explained;5. CKD and refractory hypertension- refractory to 4 or more antihypertensive agents6. Persistent abnormalities of serum potassium;7. Recurrent or extensive nephrolithiasis; or8. Hereditary kidney diseaseHere, the patient does not have acute renal failure or stage 4/5 renal insufficiency. There is no evidence of significant albuminuria, recurrent or extensive nephrolithiasis or hereditary kidney disease. The patients GFR and potassium were both recently tested and found to be within normal ranges. The patient also has no history of refractory hypertension. While the patient does have a history of blood in urine, this can be attributed to the removal of a bladder stone. KDIGO criteria for a nephrology referral have not been met. Therefore, a referral to a nephrologist is not medically necessary for treatment of this patients 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 morphine 30 mg, two tablets, two times per day. The Center for Disease Control 2016 Guidelines, adopted and restated by the American Society of Interventional Pain Physicians, clearly state that clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety and clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.Here, the patient has been a chronic opioid user. Since beginning an opioid regimen, there is no documentation of meaningful improvement in function or pain. There is also evidence suggesting that continued opioid use could be dangerous for this patient with opioid user disorder. The patient signed and understood the implications of a pain contract. The patient violated this contract, knowing that by doing so, the clinical provider would cease prescribing opioids. The records indicate that the patient was referred back to the chemical dependence program. The records further indicate that the patient did not avail himself of this program, and instead sought approval from an out-of-network pain physician to continue his opioid medications. Of note, the enrollee was also instructed to seek care at the emergency department if significant withdrawal symptoms occurred. The recommended chemical dependence program would also assist in medical management of withdrawal symptoms. The patient is a long-time opioid user for whom there is no documented improvement in function or pain. Evidence suggests that continued opioid use could be dangerous for this patient with opioid use disorder. Therefore, the requested prescription for morphine 30mg, two tablets, twice daily is not medically necessary for treatment of this patients chronic pain.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 anesthesiology and pain management, and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Afrezza. The submitted documentation supports the medical necessity of the requested medication. This patient has variable post meal glucose control, including hypoglycemia after meals. Afrezza is a rapid acting insulin with a quick onset of action. This medication can help decrease hyperglycemia as well as avoid hypoglycemia. This patient has severe glycemic fluctuations and requires additional prandial insulin shots. The patients provider has recommended Afrezza insulin in addition to the current insulin regimen, which is a combination of basal insulin and a prandial insulin. Afrezza is medically indicated in this clinical setting and is likely to improve the patients glycemic control. Therefore, Afrezza is medically necessary for the treatment of this patient. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for biofeedback therapy. The American College of Gastroenterology (ACG) guidelines for the management of benign anorectal disorders recommend anorectal manometry to determine whether a functional disorder is present, and a physical functional performance test, such as a balloon expulsion test, when evacuation or outlet disorder is suspected. In this case, both of these tests have been performed. The patient has failed multiple medical therapies and has had symptoms and testing consistent with constipation due to pelvic floor dysfunction or dyssynergia. Thapar and colleagues have found that for patients who do not demonstrate significant structural abnormalities, such as this patient, biofeedback therapy can be effective. Under these circumstances, the requested biofeedback therapy is medically necessary to treat the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a CT scan.Findings:  Two of the three physician reviewers found that the CT scan that was performed was likely to be more beneficial for treatment of the patients condition than any other available standard therapy. Medical literature supports the use of CT imaging to screen for malignancy in patients with dermatomyositis. The association between dermatomyositis and internal malignancy is well established. Their data suggests that effective malignancy screening of dermatomyositis patients often requires evaluation beyond a history, physical examination, and age-appropriate cancer screening. An extensive search for malignancy, particularly computed tomographic scans, may be warranted in at least a subset of patients with dermatomyositis and risk factors of malignancy. In this case, the patient had both dermatomyositis and risk factors of malignancy. Accordingly, the CT scan that was performed was likely to be more beneficial for treatment of the patient's condition than any other available standard therapy.Final Result: Two of the three reviewers determined that the services in issue were likely to be more beneficial for the patients medical condition than any other available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:All three reviewers are board certified in interventional radiology and diagnostic radiology, and all three reviewers 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

The parent of an enrollee has requested authorization and coverage for bilateral mastectomy and nipple reconstruction. The submitted documentation supports the medical necessity of the requested services in this clinical setting. This patient has persistent gender dysphoria and has found continuing binding untenable in the long-term. The Health Plan noted that gender reassignment surgery may be necessary for patients who are at least 18 years of age. However, this minimum age is arbitrary, and does not reflect that this surgery is often necessary for transgender male teenagers to be able to socially transition and lead a normal adolescence. The World Professional Association for Transgender Health (WPATH) Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People states that chest surgery under these circumstances is often necessary in patients under 18, particularly those who have extended periods of social transition and have started testosterone. Chest surgery for transgender male teenagers has been demonstrated to be an effective treatment for gender dysphoria in minors with persistent gender dysphoria. Prolonged chest binding can have negative health consequences, and it is not a reasonable alternative for this patient to bind his chest until he is 18 years of age. Approximating a male nipple, in size and placement, is part of establishing a normal appearing male chest, which is part of the medically necessary treatment of gender dysphoria. All told, the requested bilateral mastectomy and nipple reconstruction are medically necessary for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Humira 40 mg/0.8 ml pen. The submitted documentation supports the medical necessity of the requested medication. This patient has tried and failed therapy with topical steroids. The Health Plan noted that the patient has not yet tried and failed the preferred formulary first-line systemic agents, including methotrexate, cyclosporine or acitretin. However, because the medical records show significant transaminitis, the use of methotrexate or acitretin would not be recommended in this case. Per the records, the Health Plans preferred oral systemic agents would be contraindicated due to comorbidities. Therefore, Humira 40 mg/0.8 ml pen is medically necessary for the treatment of this patient. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for breast MRI. There is a lack of peer-reviewed literature supporting the use of screening breast MRI in a patient with a calculated lifetime risk of cancer of less than 20%. In this case, the abnormal results of the thermal breast imaging study do not, in and of themselves, indicate the need for a breast MRI study. The patient is refusing the standard screening evaluation of mammography. If the patient had screening mammography that showed dense breasts with suspicious findings, however, an MRI would be an appropriate test. On the basis of her medical records, history, and prior breast imaging studies (particularly the lack of any mammograms), screening breast MRI is not medically necessary for the patient at this time.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 radiology, with a primary specialty certificate 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.