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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  During the dates of services in dispute, the patient was practicing being out of the treatment setting.  It is not uncommon to provide day passes to patients in this clinical setting to ensure they do well prior to discharge back to the community and engaging the patients in a lower level of care.  In this case, the patient had longstanding self-image beliefs which needed to be rectified and worked through while maintaining appropriate weight gain as well as ensuring stability of vital signs.  The current medical evidence supports the services at issue in this patients case.  Therefore, partial hospitalization services were medically indicated for the treatment of this patient. 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 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 his hepatitis C virus.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The goal of hepatitis C eradication exists irrespective of fibrosis score.  However, the medical record indicates ongoing illicit drug use. In the context of ideally achieving the medically necessary goal of hepatitis C virus eradication, active recreational use of illicit substance raises concern for non-optimal adherence to hepatitis C treatment.  The literature supports that frequent drug use during treatment was associated with lower sustained virologic response rates than drug abstinence. As such, medical necessity of Harvoni treatment at this time is not demonstrated.  In sum, Harvoni 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 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 a liver single photon emission computed tomography (SPECT) scan for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this patients case.  Contemporary noninvasive measurement of liver fibrosis is now made serologically and/or by elastography.  Having been supplanted by newer noninvasive liver probes, quantitative liver-spleen scanning is rarely used.  This modality is not standard of care in this clinical setting.  Therefore, the superior efficacy of a liver SPECT scan has not been established. Final Result: Two 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 internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for treatment of his hepatitis C virus (HCV).   Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) guidelines, relative to this patients case, state: `Daily daclatasvir (60 mg*) plus sofosbuvir (400 mg) for 12 weeks is a recommended regimen for treatment-naive patients with HCV genotype 3 infection who do not have cirrhosis. Rating: Class I, Level A`.  The medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. However, the submitted records reflect illicit drug use. In the context of achieving the medically necessary goal of hepatitis C virus eradication, active recreational use of illicit substances raises concern for non-optimal adherence to hepatitis C treatment. The literature supports that frequent drug use during treatment was associated with lower sustained virologic response rates than drug abstinence. In the context of achieving the medically necessary goal of HCV eradication, the patients positive drug screen raises concern for non-optimal adherence to HCV treatment, when provided. As such, the requested medications are not medically necessary for treatment of the patients medical condition at this time. Final Result: The reviewer determined that the requested medications 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 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 Harvoni for treatment of her medical condition.  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 guidelines recommend that treatment-naive genotype 1a 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested laparoscopic anti-reflux surgery (LINX) for treatment of her medical condition.  Findings:  Two physician reviewers found that the U.S. Food and Drug Administration (FDA) approved the LINX Reflux Management System for lower esophageal sphincter augmentation. Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate GERD and a hiatal hernia less than 3 cm. The device is a ring made up of a series of magnets that have sufficient attraction to increase the lower esophageal sphincter (LES) closure pressure, but allow for food passage with swallowing. While the results from early studies at four years are encouraging, there was no control group. This patient may have supra-esophageal or extra-esophageal symptoms of GERD. This is a particularly difficult subgroup of individuals to treat because symptoms are often multifactorial and respond poorly to measures to reduce proximal acid reflux. In this subgroup, surgical fundoplication has shown disappointing results and is generally not recommended. Similarly, there is limited medical evidence from controlled trials that the LINX device would be beneficial in this subgroup. Based on the limited of evidence of benefit, even in heartburn patients, and in particular the subset with supra-esophageal GERD, the requested procedure is not likely to be more efficacious than standard therapy in treatment of this patients medical condition.   Final Result: Two reviewers determined that the requested procedure is 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 internal medicine with sub-specialty certification in gastroenterology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein blood testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that in this circumstance primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of LDL, HDL subclasses, lipoprotein(a), C-reactive protein, high sensitivity CRP, insulin, fibrinogen, genetic testing and homocysteine (Greenland et al).  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. For example, randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcome benefits. Likewise, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there are no controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. For these reasons, lipoprotein blood testing was not likely to be more beneficial for diagnosis and evaluation of the patients medical condition than standard modalities.   Final Result: Three reviewers determined that the service at issue was 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: One reviewer is board certified in internal medicine with sub-certification in interventional cardiology and is actively practicing. Two reviewers are board certified in internal medicine with sub-certification in cardiovascular disease 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 medical condition.  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 (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks, or with Sovaldi and peg-interferon with ribavirin for 12 weeks. This is based on the ALLY-3 study and the BOSON trial, which showed cure rates of over 95% with either regimen (Nelson, et al; Foster, et al).  However, delay in treatment may result in decreased survival, and no alternative therapy has been approved (Jezequel, et al). For these reasons, treatment is indicated in this case regardless of fibrosis stage, and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the skin graft product (Matristem Micromatrix) for treatment of his medical condition. Findings:  Two physician reviewers found that treatment for non-healing wounds in the lower extremity are a very difficult condition.  There are currently a wide variety of products available for soft tissue grafting and wound treatment. These products are generally classified as products derived from the individuals own body, products derived from humans other than the individual themselves, products derived from non-human organisms, products derived from man-made material and products derived from a mix of materials of various origins. With the use of these grafting/wound treatment techniques there are a limited number of comparative studies available addressing the clinical outcomes for autographic, xenographic and composite products and the results vary. The comparative data available demonstrates a wide range of outcomes with some studies reporting no clinical differences and others indicating significant differences in rate of healing.  In this case, there is a lack of peer reviewed studies available to evaluate the safety and efficacy of the Matristem Micromatrix. Therefore, the skin graft product (Matristem Micromastrix) has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were not and 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 reviewers are board certified in podiatry 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:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis has been demonstrated to be of particular benefit in patients with extremely dense breast tissue.  Overall, the addition of this technique has resulted in a decrease in callbacks and increase in detection of small cancers.  Breast tomosynthesis often allows the reader to separate dense tissue from underlying mass/architectural distortion.  Therefore, the addition of breast tomosynthesis was likely of more benefit to the patient than had the examination been done with the two-dimensional technique alone.  Final Result: Three 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:   The parent of an enrollee has requested a continuous glucose monitor for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the requested services have been established as medically necessary in this clinical setting. The patient has wide glycemic excursions, nocturnal hypoglycemia, and poor overall glycemic control despite adherence to a regimen of insulin pump therapy and frequent blood glucose monitoring.  His eating habits and activity are not always predictable, and he cannot express symptoms of hypoglycemia or hyperglycemia. Continuous glucose monitoring is the only tool available to enable the parents to track glucose trends and to set parameters for alarms of high and low blood sugars. Knowledge of blood glucose trends will help prevent episodes of life-threatening severe hypoglycemia and severe hyperglycemia. Use of continuous glucose monitoring will enable his parents and medical team to develop more confidence in bolus dosing and fine-tuning of doses without having fear of hypoglycemia. These advantages are especially of importance in children who cannot express symptoms of hypoglycemia and hyperglycemia and who are at high risk of having life-threatening acute complications of type 1 diabetes. Feasibility studies have shown that more than 40% of young children are able to safely use continuous glucose monitoring on a near-daily basis (Tsalikian, et al). In addition, continuous glucose monitoring demonstrated frequent hyperglycemia and hypoglycemic excursions that may not have otherwise been detected. Given the above, the requested services are clinically indicated for the treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatric endocrinology 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 emergency services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not believe she was experiencing an emergency medical condition.  There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In addition, clinical exam findings did not evidence a neurologic deficit correlated with imaging evidence of grade 1 spondylolisthesis at L4-5 with canal narrowing. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the requested services did not meet prudent layperson criteria for emergency care.  Moreover, it has not been established that criteria for urgently needed services were met on the dates in dispute.  There was no documentation of spinal segmental instability on flexion and extension x-rays. There is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation the patient did not meet prudent layperson criteria for urgently needed services.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. 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.