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

Nature of Statutory Criteria/Case Summary: An enrollee has requested an acute inpatient psychiatric stay for treatment of his behavioral health condition. Findings:  The physician reviewer found that although treatment gains are optimized in community-based settings, more restrictive levels of care are often necessary to address exacerbations of chronic mental illness. In this case, the patient is diagnosed with a formal thought disorder, which as a class represents the most severe psychiatric disorders. After reviewing the record, discharge would have been inconsistent with good medical practice. Treatment at the time could not have reasonably been conducted at a less restrictive setting while less intensive services would have resulted in inadequate care. The patient endorsed both auditory and visual hallucinations. His thought processing was tangential and illogical. He was deemed gravely disabled. The inpatient team began a cross-tapering of the antipsychotic medication and recommended further work-up including neuroimaging and electroencephalography. Thus, the patient had not consolidated the treatment gains necessary to succeed in a less restrictive setting. Thereafter, the patients illness burden remained largely refractory to treatment. The inpatient team changed his antipsychotic medication. The patient remained disorganized and internally preoccupied. The patient does have a supportive family, which will be instrumental in his recovery. However, he will more than likely decompensate and require prompt re-admission in the event of a premature discharge. Currently the patient remains consumed by an acute psychiatric syndrome. Thus, inpatient psychiatric care remains reasonably expected to improve his condition and prevent a more serious episode of illness. The setting is safe, appropriate and consistent with good medical practice. Thus, the services in dispute have been and remain medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the services at issue were and 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 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 Sovaldi for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the 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 (less than 12 months) due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. It is known that chemotherapy can cause an acute exacerbation of hepatitis C, underscoring the importance of expedient curative treatment in this case (Sagnelli, et al). The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatment with Sovaldi is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical lobectomy of the right lung for treatment of the enrollees adenocarcinoma of the right lung. Findings:  The physician reviewer found that while there exists some controversy regarding surgery for stage IIIa lung cancer patients, in this case, the patient is a good candidate for surgical lobectomy of the right lung. As the above references suggest, studies reveal that patients diagnosed with stage IIIa lung cancer with non-small cell tumors may benefit from surgery. The studies also show that younger fit patients without severe medical issues who undergo pre-operative chemoradiation followed by lobectomy with mediastinal lymph node dissection have longer term survival rates. Based on available studies, this patient is a good candidate for the requested procedure. In sum, a surgical lobectomy of the right lung is medically necessary for this patient.Final Result: The reviewer determined that the requested procedure 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 thoracic 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 neuropsychological testing for evaluation of her medical condition. Findings:  The physician reviewer found that the clinical records provided do not demonstrate the medical necessity for neuropsychological testing at this time. According to the records, previous psychological testing from childhood and adolescence show diagnoses of dyslexia, disorder of written expression, expressive language disorder, and attention deficit hyperactivity disorder (ADHD). There was no documentation submitted to show that the patient experienced any cognitive deficits requiring further work up. Furthermore, the patients record does not show that she suffers from any conditions requiring differentiation via neuropsychological testing. She has no psychiatric diagnoses other than ADHD.  In sum, the requested neuropsychological testing is not medically necessary for this patient.  Final Result: The reviewer determined that the requested service 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 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

ature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin for treatment of her sarcoidosis.  Findings: The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. In this patient, the submitted records do not indicate that all non-opioid treatment options have been utilized nor does the documentation indicate an optimization of all non-opioid medications.  Rather, quite large doses of opioids are being used despite research to show the dangers of a high dose and its lack of efficacy as it impacts quality of life.  The submitted records do not show that this patient has participated in behavior therapy despite much research supporting its use. The records reflect that tolerance has taken place as indicated by the use of narcotics and dose escalation which differs from the original plan by the physician who started the OxyContin.  Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The addition of more pure mu agonists will, for a short while, take care of the symptoms of mu agonist saturation; however, down regulation will transpire and then the patient is only back to where they started in terms of their pain perception. Studies reveal that such patients are worse off since they now have a much higher opioid tolerance level.  Additionally, there are other non-pure mu agonists that have long lasting duration that do not appear to have been considered based on the records provided. Further, there is no plan in place to monitor this patient with the medications both historically and currently. The documentation does not discuss other standard sarcoidosis treatments since the original notation.  Finally, multiple minimal requirements for opioid prescribing have not been met and the need to use them as the primary treatment strategy for pain has not been established. For all these reasons, the request of OxyContin is not medically necessary for treatment of the patients medical condition.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral lumbar radiofrequency ablation for treatment of his medical condition. Findings: Two physician reviewers found that lumbar medial branch radiofrequency ablation or neurolysis is a well-documented procedure which helps with chronic low back pain due to lumbar facet pain. The records indicate that this patient underwent medial branches in the past with success.  Son and colleagues noted that repeated radiofrequency ablation for lumbar facet syndrome provided successful pain relief for about 10 months in more than 85% of carefully selected patients. The procedure is successful in treating lumbar spine pain in repeated fashion.  However, since the patients prior intervention was a number of years ago, a repeat radiofrequency ablation is not indicated until a confirmation block is performed with success at diminishing the patients pain.  Therefore, the superior effectiveness of the requested services has not been demonstrated.  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: All three physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 the Afirma gene test for evaluation of her medical condition.  Findings:  Three physician reviewers found that molecular testing or gene expression classifier has been proposed as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The American Thyroid Association (ATA) Guidelines Taskforce on Thyroid Nodules and Differentiated Thyroid Cancer guidelines indicate For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the patient had a minimally enlarging nodule. The Afirma gene expression classifier was consistent with benign results. The risk of malignancy is decreased to 2.5%, per ATA guidelines. A benign result prevented an unnecessary surgery and its potential comorbidities (Alexander, et al; Duick, et al). Surgery is not necessary with this result and continued observation is recommended. Therefore, the Afirma gene test was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the 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 overturned.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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 Sovaldi and Daklinza for treatment of his 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. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks (regardless of interferon eligibility). This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). The patient is not eligible for interferon-containing regimens due to rheumatoid arthritis, which can be exacerbated by interferon, and which is listed as a boxed warning on the prescribing information approved by the U.S. Food and Drug Administration (Ionescu, et al). The guidelines cite study data reporting that delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  According to Skaane and colleague, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues note that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.in this clinical setting.  Final Result: Two 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:  All three reviewers are board certified in diagnostic radiology 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 OxyContin for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the medication at issue in this clinical setting.  The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the acute, chronic, or acute on chronic setting.  The records indicate that the WHO ladder for pain relief was followed in this case.  There is a lack of evidence to recommend one long-acting pure mu agonist opioid over another.  The medical records document that this patient experienced significant pain, and the current medical evidence supports the medication at issue in this patients case.  All told, OxyContin was medically indicated for the treatment of this patient. Final Result: The reviewer determined that the medication at issue was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 24 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the 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 patient failed therapy in the distant past, but which therapy is not reported. Per guidelines, non-cirrhotic genotype 1 patients who have failed either interferon-based therapy (which was the primary U.S. Food and Drug Administration (FDA)-approved therapy at that time) or an interferon regimen with a protease inhibitor should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is FDA-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Afdhal, et al, Lawitz et al). The guidelines also recommend the use of Viekira Pak and ribavirin in treatment-experienced genotype 1b patients, and no clear contraindications to this regimen are provided in this case. For these reasons, treatment with Harvoni for 12 weeks or Viekira Pak for 12 weeks are supported, but the requested treatment with Harvoni for 24 weeks is not supported 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys spray for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records do not document that the patient has exhausted non-opioid treatment options.  The clinical notes indicate that the providers long-term plan for treating tolerance is not clear.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Subsys spray is not medically indicated for the treatment of 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.