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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his medical condition. Findings:  The physician reviewer found that the request for Norco is not medically necessary for treatment of the patients medical condition. According to researchers, several prominent guidelines recommend that patients on long-term opioid therapy have periodic urine drug monitoring for appropriate use. In this case, the patient presents with chronic pain of the lower left extremity. The patient has had inconsistent drug testing, for which his provider has been weaning down his medication. Based on the above, the request for Norco is not indicated for this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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 Harvoni for treatment of her 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline 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. For these reasons, Harvoni is medically indicated 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. 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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive non-cirrhotic genotype 1b patients should be treated with Harvoni for eight weeks, or with Viekira Pak for 12 weeks. Although treatment of hepatitis C is necessary, based on medical literature, there is a lack of documentation submitted for review that provides justification to support coverage of Harvoni over Viekira. There is a lack of head-to-head clinical trials comparing Harvoni to Viekira. For these reasons, the requested treatment with Harvoni has not been established as medically necessary for the treatment of this patients hepatitis C infection. 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 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 decompression therapy (Vax-D table) for treatment of her medical condition.   Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  Overall, the literature does not support the use of traction for treatment of low back pain with or without radicular symptoms.  The medical records indicate the patient has back pain. Other diagnoses applied to her are of uncertain accuracy based upon the clinical notes submitted.  In sum, decompression therapy (Vax-D table) was not likely to have been superior over other treatment options. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in physical medicine and rehabilitation and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested porcine xenograft for treatment of her medical condition. Findings:  Three physician reviewers found that biological dressings, such as cadaver allografts and porcine skin xenografts are utilized to treat partial thickness burns. These dressings provide temporary wound coverage until full healing can be achieved. Burns can be treated with topical medication such as Sulfamylon or with biologic dressings such as xenografts. A biologic dressing is not expected to survive on a partial thickness burn, but is used instead to protect and sterilize the burn and prevent progression to a full thickness burn. According to the American Burn Association on the surgical management of the burn wound and use of skin substitutes Xenograft (pigskin) is used at many institutions in the same manner as allograft. Necrosis in the zone of stasis (the damaged but potentially viable area of thermally injured tissue surrounding irreversibly necrotic skin) could be avoided by optimal treatment of the wound with a biologic dressing such as xenograft. Thus application of xenograft on a debrided mid-dermal burn might prevent/obviate the need for excision and autografting. In sum, the porcine xenograft is supported by evidence published in the peer reviewed medical literature. Therefore, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were 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:  All three reviewers are board certified in plastic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline 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.  All told, Harvoni is medically indicated 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center (RTC) services and partial hospitalization program (PHP) treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the services at issue were not medically necessary for treatment of the patients medical condition. In this case, the patient did not meet criteria for RTC services and she did not meet criteria for PHP services. Specifically, there is a lack of evidence submitted for review demonstrating that the patient needed the required structure of residential or PHP, respectively, to motivate her to make progress, or to prevent her from acting on her behavioral health condition. There is also a lack of evidence that she was preoccupied with disordered thoughts about her behavioral health condition in excess of several hours daily. The documentation demonstrates that she consistently appeared well motivated and cooperative with her treatment, and even expressed the desire to be at the intensive outpatient program level of care while she was being treated at the PHP. In sum, the clinical documentation submitted for review has not established the medical necessity for the services at issue.  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 with sub-specialty certification in child and adolescent 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 requested magnetic resonance imaging (MRI) of the knee for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In this patients case, a trial of conservative treatment is appropriate, as acute pain will often resolve without more aggressive intervention.  It is not unreasonable for him to be evaluated by an orthopedist.  The primary reason to obtain an MRI is in preparation for surgery, which the patient may need.  This patient has had symptoms for over one year, has not had any recent trauma, and there is no indication that he has an infection or other condition that might demand immediate evaluation.  At this time, there is a lack of support for the requested MRI of the knee in this clinical setting.  All told, the requested MRI of the knee is not medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz bilateral knee injections for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. Furthermore, the practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. In sum, further hyaluronan injections to be utilized in the management of this patients osteoarthritis are not medically necessary given the lack of support in the evidence based literature.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Mepron for treatment of her medical condition. Findings:  The physician reviewer found that Babesia duncani infection is extremely rare, with only a few reported cases. There is a lack of validated laboratory assays for this species. Clinical experience with treatment of infection due to Babesia duncani is limited to case reports in one area of the United States. There is no indication for Mepron in the treatment of this disease. Babesia microti is a more common species causing acute illness with fatigue and muscle weakness and anemia. The treatment for Babesia microti is atovaquone and azithromycin for a 7-10 day course, and there is no repeat course indicated. The clinical presentation of this patient is not consistent with Babesia duncani or Babesia microti infection. There is a lack of validated titers present and polymerase chain reaction (PCR) or fluorescence in situ hybridization (FISH) assays were not provided. Therefore, the medical necessity for the use of Mepron has not been established in this clinical setting. Final Result: The reviewer determined that the medication at issue was not and is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine and 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 residential treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was medically stable. She was actively participating and highly engaged in her treatment plan. She demonstrated motivation and willingness. She showed a high degree of insight into her functioning. She no longer required the 24-hour restricted setting of a residential treatment program. Her medication management did not require a residential setting. She could have safely and effectively continued her recovery at a lower level of care such as intensive outpatient program services. Thus, the residential treatment services at issue were not and are not medically necessary for treatment of the patients behavioral health condition.  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 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 Forteo for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Osteoporosis is an increasingly widespread condition, and fractures are the most dangerous aspect of osteoporosis.  Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates.  While these can be effective medications, antiresorptive agents can be difficult for patients to tolerate and can lead to severe gastroesophageal reflux disease.  Further, the antiresorptive agents, including both the bisphosphonates and newer antiresorptive agents, such as Prolia, may lead to dangerous outcomes, including osteonecrosis of the jaw.  Newer treatment agents have become available over the past few years, including Forteo.  This patient has experienced gastrointestinal distress while on bisphosphonates.  Further, her multiple dental procedures put her at risk for osteonecrosis of the jaw.  All told, Forteo is medically indicated 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Picato for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. This patient has a history of facial basal cell carcinoma.  His occupation involves performing procedures which produce a non-sterile environment.  Treatment with Picato gel is preferred due to the limited downtime associated with the treatment.  Picato gel is a U.S. Food and Drug Administration (FDA) approved three-day treatment for actinic keratosis.  The first-line therapy typically involves a 21-day course of therapy.  Significant cutaneous inflammation is associated with use of these medications.  As the patient is considered to be at risk for airborne infectious exposures due to his occupation, a concise treatment period is appropriate.  All told, Picato is medically indicated 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Gammaplex brand, intravenous immune globulin (IVIG) home infusions for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of standard guidelines in the treatment of autoimmune chronic urticaria. There are several published guidelines for suggestions on the treatment with most agreeing that maximal antihistamine therapy should be used followed by anti-inflammatory agents, omalizumab, and immunosuppressive agents.  Other therapies exist but have limitations.  In this case, the patient has failed two of the therapies. However, there is no documentation submitted that demonstrates she has failed or has a contraindication to other available therapies.  Although there are case reports and series of responses to IVIG, there is a lack of large studies or randomized controlled trials assessing its use. Given the lack of large studies, and no documentation of failure of more commonly used therapies, the request for IVIG is not likely to be more beneficial than standard therapy. Final Result: Two 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:  One reviewer is board certified in internal medicine and allergy and immunology and is actively practicing. Two reviewers are board certified in dermatology and is 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.