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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for narcotic pain medication (without having to cease using marijuana first) for treatment of his medical condition. Findings: The physician reviewer found that there is insufficient support for the requested medication in this clinical setting. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Additionally, the patient is using medical marijuana which is not indicated for concurrent use with opioids. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In sum, narcotic pain medication (without having to cease using marijuana first) 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center (RTC) services for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has several risk factors for self-harm and possible suicide. The patients history requires extreme caution in treatment. It is critical that she be fully stabilized before discharge to a lower level of care, as her history puts her at tremendous risk of relapse and self-harm if discharged prematurely. Therefore, the medical records demonstrate that RTC services were medically necessary in order to make sure the patient was stable enough for discharge. Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 40 hours per week direct intensive of applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review indicates that the patient has behavioral issues that include elopement and self-injury in the school setting. There is research showing that behavioral health treatments including ABA are effective for addressing these behaviors. Thus, ABA services are clinically indicated. ABA is a prescribed set of skills that need to be taught in order to have functional communication and social interaction. These skills sets are broken down into smaller parts and then are taught at the lowest level needed for each patient. These skill sets are designed to remediate the core problems of the autism spectrum disorders. In this case, the patient needs ABA services in the school setting to address behaviors specifically self-injury, elopement and safety issues. However, the requested additional 20 hours of ABA services are not indicated. In this case, an additional seven hours of ABA services rendered in the school setting is clinically indicated. As such, 27 hours per week direct intensive of ABA is medically necessary for treatment of the patients autism.  Final Result: Two reviewers determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral whole breast ultrasound for evaluation of her medical condition.  Findings:  Three physician reviewers found that while screening ultrasonography may mildly increase the number of cancers detected, there are reports of a number of false positives (Chae, et al). It should also be noted that the issue of better evaluation of increased breast density has largely been replaced by the advent of tomosynthesis. Whole breast automated sonography has not been widely performed, whereas tomosynthesis is rapidly becoming the diagnostic test of choice for dense breasts. The American College of Radiology has rated the various modalities in terms of appropriateness to screen for breast cancer. Ultrasonography has a rating of usually not appropriate for breast cancer screening in patients with an average risk. In conclusion, while breast sonography is a possible adjunct to mammography, its diagnostic accuracy alone is relatively poor, and it is not recommended as a screening modality. Given the above, bilateral whole breast ultrasound was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  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:   The parent of an enrollee has requested 40 hours per week applied behavioral analysis (ABA) for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the documentation submitted for review indicates that the patient has behavioral issues that include elopement and self-injury in the school setting. There is research showing that behavioral health treatments including ABA are effective for addressing these behaviors. Thus, ABA services are clinically indicated. ABA is a prescribed set of skills that need to be taught in order to have functional communication and social interaction. These skills sets are broken down into smaller parts and then are taught at the lowest level needed for each patient. These skill sets are designed to remediate the core problems of the autism spectrum disorders. In this case, the patient needs ABA services in the school setting to address behaviors specifically self-injury, elopement and safety issues. However, the requested additional 20 hours of ABA services are not indicated. In this case, an additional seven hours of ABA services rendered in the school setting is clinically indicated. As such, 27 hours per week direct intensive of ABA is medically necessary for treatment of the patients autism.  Final Result: Two reviewers determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested clostridial collagenase histolyticum (Xiaflex) for treatment of his medical condition.  Findings:  The physician reviewer found that according to the American Urological Association (AUA), Peyronies disease can be treated with Xiaflex injections in patients for the reduction of penile curvature in patients with stable Peyronies disease. Per the AUA guidelines, patients with penile curvature of more than 30 degrees and less than 90 degrees and intact erectile function with or without medications, are good candidates for this treatment. Further, intralesional therapy with Xiaflex has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult men with Peyronies disease with a palpable plaque and curvature deformity of at least 30 degrees at the start of therapy. All told, there is adequate scientific evidence supporting the medical necessity of the requested Xiaflex injections for treatment of this patients Peyronies disease.  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 urology 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 his hepatitis C virus (HCV).  Findings:  The physician reviewer found that per the combined American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), AASLD/IDSA guidelines treatment is recommended for all patients with chronic hepatitis C virus (HCV), except those with short life expectancies owing to comorbid conditions. This recommendation was given a rating of Class I, Level A. The guidelines recommend clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving a sustained virologic control (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated (93%, 82%, and 88%, respectively; P =.003). The study argues for consideration of earlier initiation of treatment (Jezequel, et al). Therefore, based on the current recommendations, the requested medication is 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 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 gene testing (Coagulation factor V) for evaluation of her medical condition.   Findings:  Three physician reviewers found that factor V Leiden testing is recommended in women with venous thromboembolism during oral contraceptive use. In contrast to general screening before administration of oral contraceptives, targeted testing of women with a personal or family history of venous thrombosis is advisable. Routine screening for factor V Leiden in asymptomatic women contemplating or using oral contraceptives is not recommended, except for those with a personal history of thromboembolism or other medical risk factors. In this clinical setting, the patient presented with a strong family history of factor V Leiden mutation.  Therefore, the test at issue was likely to be more beneficial for evaluation of her 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 hematology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was approved for clinical use by the U.S. Food and Drug Administration (FDA). Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been added to standard mammographic protocol, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this tomographic technique brings to radiologists interpreting mammograms. The technique often allows the reader to separate dense glandular elements from underlying mass or architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Thus, breast tomosynthesis was likely to have been more beneficial for evaluation of this patients medical condition than any available alternative. Final Result: Two reviewers determined that the diagnostic procedure 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 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 Harvoni for treatment of his 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. 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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 Otezla for treatment of her medical condition. Findings: The physician reviewer found that psoriasis is a chronic inflammatory skin disease affecting approximately 2% of the US population and 4.8% of people worldwide. Approximately 30-45% of those affected first experience symptoms during childhood or adolescence (Marji, et al). This skin disease typically presents with sharply demarcated, inflammatory, erythematous plaques with characteristic silver-white scaling due to epidermal hyperproliferation and parakeratosis secondary to the inflammation. Psoriasis has a high negative impact on the quality of life, especially in patients moderately or severely affected by the disease (Navarini and Trueb). About 20% of patients suffer from severe psoriasis, necessitating systemic drugs such as Acitretin, methotrexate, cyclosporin A or the newer biologic agents. This patient has severe plaque psoriasis that requires systemic treatment. Otezla is approved by the U.S. Food and Drug Administration (FDA) for treatments of such patients. All told, the requested Otezla is medically necessary for treatment of this 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 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 speech therapy twice per week for treatment of his medical condition.  Findings:  The physician reviewer found that the patient presents with anoxic encephalopathy; recovery from this type of injury, like most brain injuries, is often slow and incomplete. Therapies have been shown to be beneficial in facilitating recovery, but results can plateau. Active efforts at therapy are dependent on patient participation, which is a function of capabilities and motivation. In this patients case, the submitted records indicate that his recovery has slowed or plateaued. There is a lack of clinical documentation demonstrating that the patient was benefitting from continued therapy. In the absence of evidence that additional speech therapy is likely to result in an improved functional outcome, the medical necessity of the requested speech therapy twice per week has not been established.   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 neurology 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 medial branch radiofrequency ablation for treatment of her medical condition. Findings: Two physician reviewers found that Manchikanti and colleagues conducted a thorough review and concluded that there is significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain. Similarly, McCormick and colleagues studied the long-term outcome of radiofrequency lesioning and found benefit that lasts from six months to two years. Thus, the medial branch radiofrequency ablation is likely to have been more beneficial for treatment of this patients medical condition than any available standard therapy. Final Result: Two 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 anesthesiology with sub-specialty certification in pain management 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.