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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of Zepatier for 12 weeks for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that treatment naive, genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: The patient has requested authorization and coverage for Tramadol Hcl 50 mg quantity 60 with one (1) refill for treatment of radiculopathy, somatic dysfunction, and osteoarthritis. Findings:  The physician reviewer found that guidelines offer specific requirements for the ongoing use of opiate pain medication to treat chronic pain. Recommendations state the lowest possible dose be used as well as ongoing review and documentation of pain relief, functional status, appropriate medication use and its side effects. Documentation of the patients response to pain medication should include the duration of symptomatic relief, functional improvements, and the level of pain relief. However, this patients records do not demonstrate that treatment with Tramadol did or will decrease the level of pain the patient reported from one visit to the next. In addition, there was no noted functional improvement or improved pain noted during the duration of the prescription for Tramadol. There is no indication that the patient has failed or has a contraindication to first-line agents such as non-steroidal anti-inflammatory drugs (NSAIDs). 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 neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for high frequency chest wall oscillation device (inCourage Airway Clearance System) for treatment of the enrollees bronchiectasis.  Findings:  Two physician reviewers found that the management of bronchiectasis is dependent upon the etiology. The vast majority of modern literature focuses on the cystic fibrosis cohort of patients. This body of data, though, has not translated over to the less studied non-cystic fibrosis bronchiectasis patients and many of these therapies are utilized in the management of these patients even though literature is sparse. The medical literature comparing HFCWO to standard airway clearance techniques has demonstrated an improvement in quality of life and patient comfort with HFCWO and a trend in reduction of expectorated sputum. A study attempted to find the most efficacious technique for airway clearance in non-cystic fibrosis bronchiectasis and compared HFCWO to more traditional methods of chest physiotherapy. The HFCWO and airway clearance groups had similar improvements in quality of life, but the HFCWO group showed significant improvement in respiratory physiology, blood inflammatory mediators and dyspnea when compared with the standard therapy with airway clearance group. In sum, airway clearance plays a role in the management of non-cystic fibrosis bronchiectasis. Due to the advanced nature of the patients lung disease and her frequent exacerbations, a HFCWO vest is indicated for this patient. Given that the patient has been assessed with the InCourage device and reports improvement in breathing and sleeping, the HFCWO device (inCourage Airway Clearance System) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure is 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in pulmonary disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for 100 hours per month of applied behavioral analysis (ABA) therapy in the school setting for treatment of the autism spectrum disorder. Findings:  The physician reviewer found that based on the documentation submitted for review, the request for 100 hours per month of ABA therapy in the school setting has been established as medically necessary. ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients parents are requesting continued coverage of ABA therapy in the school setting to address aggression, verbal protests, transitions, compliance, conversation, attending to task, answering wh questions and other issues. A treatment plan has been developed that is consistent with the patients essential health needs and consistent with the diagnosis of autism targeting behaviors and promoting generalization. The recommendation of ABA in the school setting has been recommended to promote the patients independence by addressing his deficits related to his diagnosis of autism. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 reimbursement for Oncotype DX test (CPT 81519) for evaluation of the enrollees breast cancer ductal carcinoma in situ (DCIS).  Findings:  The physician reviewers found that recently, several groups have identified panels of gene expression markers/signatures that appear to predict the baseline risk of breast cancer recurrence after surgery, radiation therapy and endocrine therapy for hormone receptor positive tumors in women with node negative disease. This test is generally used for T1, T2 estrogen receptor positive, node negative patients to estimate risk of distant metastasis. In this case, the patient has DCIS. This test stratifies patients into high and low risk groups. At this time, the evidence is insufficient to determine the effects of this technology on health outcome of patients in this clinical setting. As such, the services at issue were not likely to have been more effective than the available standard therapy for the evaluation of this patients medical condition. Final Result: All three reviewers determined that the services 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: Physician reviewers number one, two, and three are board certified in radiation oncology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:An enrollee has requested authorization and coverage for Norco 10/325, one tablet QID prn and MS ER 15 mg, one tablet TID prn. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications. Clinical practice guidelines do not support renewing opiate medications in a high-risk patient. The positive urine toxicology for methamphetamine and the history of overdose when taking Percocet indicate that this patient is high-risk. These are also violations of her opiate maintenance agreement. There are alternative pain medications which she has not reportedly trialed yet. The medical evidence does not support the requested medications in this clinical setting. All told, Norco 10/325, one tablet QID prn and MS ER 15 mg, one tablet TID prn are not medically necessary for the treatment of this patient.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 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 reimbursement for Emend 125 mg for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the documentation provided does not support the medical necessity for the medication at issue in this clinical setting. The medical literature recommends control of postoperative nausea as an important principle in facial aesthetic surgery. One of the anesthesia requirements for facial cosmetic surgery includes prevention of postoperative nausea and vomiting. The patient was prescribed Emend 125 mg (one tablet) for postoperative nausea and vomiting following the patients rhinoplasty and facelift.  However, in this patients case, the 125 mg tablet of Emend exceeds the recommended 40 mg tablet as indicated on the medication labeling for postoperative nausea and vomiting. In addition, Emend is recommended to be given one to three hours prior to anesthesia. Per the record, the provider prescribed the medication to be taken the night before. There was insufficient documentation provided by the treating surgeon to justify 125 mg tablet of Emend to be taken the night before the surgery. Therefore, Emend 125 mg administered was not medically necessary for the treatment of this patients medical condition. Final Result: The reviewer determined that the medication at issue was 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 plastic 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for testing for the amount of a type of drug (tumor necrosis factor (TNF) antagonists) in the enrollees blood for evaluation of the enrollees ulcerative colitis. Findings:  Two physician reviewers found that there is insufficient medical evidence to support the effectiveness of Prometheus Anser testing compared with conventional courses of action in the management of ulcerative colitis. The studies that discuss the use of anti-vedolizumab antibodies and serum levels are small, retrospective, and/or observational rather than controlled in nature, preventing firm conclusions about cause and effect. These small studies at best demonstrated correlations between treatment response and the presence of anti-vedolizumab antibodies, which do not allow firm conclusions regarding cause and effect. Additionally, the antibodies can be transient. Controlled studies are lacking to show that use of the test results in improved long-term health outcomes for patients with ulcerative colitis compared with conventional management. Final Result: The reviewers determined that the testing 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology and are 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue. The patient was not experiencing post-acute withdrawal symptoms. He was not a danger to himself or others, and he was not aggressive or hostile. He was medically and psychiatrically stable. No medication changes had occurred. There were no emotional, behavioral, cognitive, or impulsive symptoms that would have warranted this level of care. He was motivated and working the program. Although he continued to struggle with his emotions, he could have continued treatment at an ambulatory level of care, where he could have continued to further develop insight and solidify coping skills, as well as take advantage of community-based 12-step programs. His family was supportive and involved in his recovery. Given his extensive substance abuse history with multiple prior residential treatments, the patient was well aware of, by his own admission, his propensity towards relapse. However, this is an inherent risk in the substance abuse population and in and of itself is not a reason to keep a patient in this level of care.  During the timeframe in dispute, he no longer met criteria for residential level of care.  All told, residential treatment center services were not medically necessary for the treatment of this patient.  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 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the Level of Care Utilization System (LOCUS) criteria, the patient met criteria for treatment in a less restrictive environment. The patients risk of harm scores is two (2), mild risk of harm. The patient does not have a history of suicide attempts or suicidal ideation. The patients history includes binge drinking. The patients functional status score is three (3), moderate impairment. The patient is currently unemployed. The patient has interpersonal issues with family when actively drinking. However, the family is supportive of sobriety. The patients medical, addictive and psychiatric co-morbidity score is three (3), significant co-morbidity. The patient has a significant co-morbidity of alcohol use disorder, anxiety, and depression. The patient has a history of elevated liver function tests (LFT) and enlarged liver. However, these medical conditions do not require 24-hour observation. The patients recovery environment score is two (2), mildly stressful environment. Per documentation, the patient does some ongoing interpersonal conflicts with others and family, typically in context of the patients alcohol use. The patients level of support score is two (2), supportive environment. The patient has a spoouse and two children who are supportive of the patients sobriety. The patients treatment history score is three (3), equivocal response to treatment and recovery. Previous treatment had kept the patient sober. However, the patient stopped going to Alcoholics Anonymous (AA) meetings after 180 days and stopped his Vivitrol and Naltrexone. The patients engagement and recovery status score is two (2), positive engagement and recovery. The patient is cooperative and compliant with treatment. The patient feels that the patient can be treated in a less restrictive environment, so the patient can be with his spouse and children. Based on these criteria, the patient has a total score of 17 and would meet criteria for in a less restrictive environment such as an intensive outpatient program (IOP). The patient continued to need treatment for alcohol use disorder, but the patient had improved enough to be treated in a less restrictive environment. Therefore, the RTC services provided were not medically necessary for treatment of the patients medical condition. 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 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 authorization and coverage for a continuous positive airway pressure (CPAP) device for treatment of the enrollees mild obstructive sleep apnea. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device. The patients Epworth Sleepiness Scale score was normal. Per the records, he does not have clinically significant hypersomnia which is a cornerstone for a diagnosis of sleep apnea. Despite that finding, he had a sleep study. The patient does not have a history of hypertension, heart disease or a stroke. In the absence of hypertension, cerebrovascular accident or cardiac disease, the criteria for the medical necessity for CPAP is an apnea-hypopnea index of 15 or higher. In this patients case, his apnea-hypopnea index was 6.0. There was one sleep position during which his AHI was 9.4, but that is not the criteria measurement. Specifically, the criteria measurement is the apnea-hypopnea-index for the entire sleep study. The current medical evidence does not support the requested device in this clinical setting. All told, the requested CPAP device is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary disease 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.