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 Ampyra for treatment of the enrollees optic atrophy and nystagmus. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Ampyra (4-aminopyridine) has been shown in clinical studies to reduce nystagmus. The literature indicates that treatment with Ampyra has been effective in stabilizing patients diagnosed with nystagmus regardless of etiology. Additionally, the records indicate that this patient has responded well to the medication. Therefore, the use of Ampyra for treatment of this patients medical condition is medically necessary. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for acupuncture. The documentation provided does not support the requested acupuncture in this clinical setting. However, the records did not include examination findings of prior acupuncture care nor what benefits this patient had achieved from those services. Additionally, the acupuncture evaluation and a recommended plan of care performed on 8/22/17, does not appear to have been based on current evaluations of the patients history, complaints, examination findings or evidence of prior acupuncture visits. A plan of care for treatment of this patients medical condition were not provided. The provider has not documented physical or orthopedic examinations of the low back. The x-ray noted in the documentation was performed on 10/30/15. Therefore, given the lack of documentation of recent workup, acupuncture is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that 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 oriental 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 reimbursement for Integra Bilayer Matrix wound graft. The Health Plan has denied this request indicating that the service at issue was considered investigational for the enrollees non-healing right leg wound. The patient presented with an extensive right leg/ankle fracture necessitating surgical correction. She sustained a deep infection which required removal of hardware as well as significant debridement of infected soft-tissue. The patient underwent IV antibiotics as well as routine debridement and other consistently used wound dressings to facilitate healing of the large wound. However, these measures did not allow for healing. The use of Integra has been well documented in the literature and is U.S. Food and Drug Administration (FDA) approved for burns and diabetic foot ulcers. Integra contains a matrix as well as other mediators allowing for significant and expedited healing of deep wounds involving the dermis. Given that the patient failed treatment with conservative standard of care treatments, the application of the Integra Bilayer Matrix wound graft provided was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: The reviewers determined that the service at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One physician reviewer is board certified in family medicine with special qualification in wound and burn care 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.Two physician reviewers are board certified in podiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for upper extremity prosthesis. The peer-reviewed literature supports myoelectric control of upper extremity prostheses as an effective and efficient means of restoring upper extremity functionality based on an individual patients needs. This patient has a congenital left upper extremity reduction deformity. The patient has been using a myoelectric upper extremity prosthesis for at least 15 years. The provider indicated that the current prosthesis was worn out and required replacement. However, the most recent physical therapy evaluation indicated that the patient was using the current prosthesis for cosmetic purposes. It had a powered grip but the patient was not able to modulate the strength. The patient was noted to be independent in activities of daily living. Current evidence based medical criteria have not been met to support the requested myoelectric prosthesis. There is no documentation that the patient had sufficient microvolt threshold in the residual limb to allow proper function of the requested prosthesis. In addition, it has been noted that the patient was not able to modulate the myoelectric grip function of the current prosthesis. Moreover, there is no documentation that standard body powered prosthetic devices could not be used or were insufficient to meet the functional needs of the patient in performing activities of daily living. Therefore, the request for an upper extremity prosthesis is not medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100/40 mg, three tablets daily for eight weeks. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollees hepatitis C. 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 3 patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. The ENDURANCE-3 trial showed a 95% cure rate with eight weeks of treatment.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100/40 mg, three tablets daily for eight weeks is medically necessary for the treatment of 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 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 reimbursement and prospective authorization and coverage for a continuous positive airway pressure (CPAP) machine for treatment of the enrollees sleep apnea. Findings:  The physician reviewer found that there is sufficient support for the equipment at issue in this clinical setting. The American Academy of Sleep Medicine (AASM) recommends offering positive airway pressure therapy to all patients who have been diagnosed with obstructive sleep apnea.  Obstructive sleep apnea is defined as either an obstructive respiratory disturbance index greater than or equal to 15 events per hour with or without symptoms, or an obstructive respiratory disturbance index between 5 and 14 events per hour that is accompanied by symptoms of uncontrolled obstructive sleep apnea, such as sleepiness, fatigue, hypertension, heart disease, diabetes mellitus type II or cognitive or mood disorders. In this case, the patients apnea index is 7 with an abnormal respiratory disturbance index of 45.3, which is consistent with significantly severe obstructive sleep apnea. The documentation available for review supports that she consistently uses the CPAP machine four hours or more per night on most nights. The current medical evidence supports the equipment at issue in this clinical setting. All told, CPAP machine was and is medically necessary for the treatment of this patient.Final Result: The reviewer determined that the equipment at issue was and 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 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 reimbursement for an oral device provided for treatment of the enrollees obstructive sleep apnea (OSA). Findings:  The physician reviewer found that the oral device provided was medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has documented OSA with a reported AHI of 14. Polysomnograms are variable and dependent upon the evaluation of the interpreter of the study. The variation of an AHI of 14, and an AHI of 15, is negligible. Given that an AHI of 15 would meet criteria for the oral device, the patients AHI of 14 has a demonstrable pathologic entity supporting the device at issue. Therefore, the medical necessity of the oral device provided has been established as medically necessary for treatment of the patients medical condition. Final Result: The physician reviewer determined that the device at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician reviewer is board certified in oral and maxillofacial 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Stelara, 90 mg every four weeks and reloading dose of Stelara 390 mg infusion The Health Plan has denied this request indicating that the requested medication, reloading dose and increase in maintenance dose are not medically necessary for treatment of the enrollees Crohns disease. Findings:  The physician reviewer found that current medical literature supports dose escalation of Stelara in this case, but not a reloading infusion. A large randomized controlled trial demonstrated safety and efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease that was resistant to anti-tumor necrosis factor (TNF) therapy, which this patient has failed. Another study showed a 73% response in patients with anti-TNF-resistant Crohns disease, and 80% of responders maintained remission for 1 year. A significant majority of these patients were able to discontinue steroids. The mechanism of Stelara (ustekinumab) is entirely different than that of anti-TNF medications, both of which the enrollee has failed.  A study showed dosing at 90 mg every four weeks was used frequently to address inadequate disease control, and a large proportion of patients were able to maintain response with dose escalation to 90 mg every four weeks.  Additionally, in this case, alternative therapies are limited.  However, there is a lack of support in the literature for a reloading infusion.  For these reasons, the request for Stelara 90 mg subcutaneously every four weeks is supported as medically necessary for the treatment of this patients Crohns disease but the reloading dose is not medically necessary. Final Result: The reviewer determined that a portion of the requested medication, reloading dose and increase in maintenance dose is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for esophagogastroduodenoscopy, flexible, transoral; with esophagogastric fundoplasty, partial or complete, includes duodenoscopy when performed.Findings:  Three physician reviewers found that patient has gastroesophageal reflux disease (GERD) based on pH recording, and he has not benefited to a significant degree from use of acid suppression treatment. In prelude to surgical intervention for GERD, researchers noted that it is critical to document the presence of abnormal distal esophageal acid exposure, especially when anti-reflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. The authors concluded that upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. This patient has undergone much of this pre-operative assessment. However, this patient has multiple contraindications to performance of the transoral incisionless fundoplication procedure including Barretts esophagus, hiatal hernia of greater than 2 cm, and a body mass index (BMI) over 35. For these reasons, the requested procedure is not likely to be more beneficial than available standard therapy for treatment of patients medical condition. Final Result: The reviewers determined that the requested procedure is not likely to be more beneficial than available standard therapy for treatment of patients medical condition.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 reimbursement for blood test (prothrombin G20210A (factor II)) for evaluation of the enrollees risk for thrombosis. Findings:  2/3 of the physician reviewers found that there is support in the medical literature for the blood test that was done in this patients case. The factor V mutation, also known as factor V Leiden, has the potential to induce hypercoagulopathy. A long airplane flight or automobile trip, as in this specific case, may trigger this condition. Importantly, the prothrombin G20210A mutation adds to this risk such that compound heterozygous patients can have up to 20-fold increased odds of developing DVT. The testing in this clinical setting would have directly altered treatment recommendations. In sum, the blood test (prothrombin G20210A (factor II)) was likely to have been more efficacious than any other methods of evaluating this patients medical condition. Final Result: 2/3 of the 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in 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: Overturned Decision of Health Plan

Standard ReviewThe patient has requested authorization and coverage for Vemlidy 25 mg once per day. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis B virus.Nature of Statutory Criteria/Case Summary: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Disease (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), which the patient is currently taking, the Vemlidy formulation of tenofovir is effective for hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease (Grant and Cotter). For this reason, the request for Vemlidy 25 mg once per day is medically necessary for the treatment of this patients chronic hepatitis B. 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

Standard Review An enrollee has requested authorization and coverage for Vemlidy 25 mg, one tablet every day for one year. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B virus. Nature of Statutory Criteria/Case Summary: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared with alternatives for the treatment of chronic hepatitis B (Terrault, et al). In comparison with tenofovir disoproxil fumarate (Viread), which the patient had been taking, the medical literature indicates that the Vemlidy formulation of tenofovir is effective for hepatitis B, and is associated with lower incidence of side effects such as osteopenia and renal disease.  For this reason, Vemlidy 25 mg, one tablet every day for one year is medically necessary for the treatment of this patients chronic hepatitis B. 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.