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 for Odefsey 200-25-25 mg tablets for treatment of the enrollees human immunodeficiency virus (HIV). Findings: The physician reviewer found that Atripla contains tenofovir disoproxil which has been associated with statistically significant reduction in renal function in several studies. Tenofovir alafenamide, contained in Odefsey, has been shown to be as effective but with a lower risk of kidney toxicity and bone density changes when compared to tenofovir disoproxil. 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 infectious diseases 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 authorization and coverage for anesthesia for dental work.Findings:  The physician reviewer found that general anesthesia for special needs patients who cannot tolerate routine dental procedures is considered a safe and effective practice.  These needs can be either medical or psychological.  Common indications for general anesthesia in these patients are a lack of cooperation and cognitive impairment, of which this patient has both.  Dental caries is a common problem in these patients.  Evidence suggests the prevalence of untreated dental caries is higher among people with intellectual disability.  Additionally, it would be difficult, if not impossible, to diagnose and/or determine the length or extent of treatment required for the dental procedure without having the ability to perform an examination due to lack of patient cooperation. General anesthesia is often employed to facilitate extensive dental treatment in patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and the likely need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for this patient.  All told, the requested anesthesia for dental work is medically indicated for the treatment of this patient.Final Result: The reviewers 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: Physician reviewer is board certified in anesthesiology 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 parent of an enrollee has requested reimbursement for dental procedure codes D7953 and D9223. Findings:  The physician reviewer found that the clinical records fail to demonstrate the dental necessity of the requested services.  The submitted documentation indicates that the procedure of grafting, D7953, was recommended to facilitate placement of a dental implant in the extraction site of tooth number 26.  The dental literature supports that following the extraction of a tooth, while a bone graft will likely result in slightly greater preservation of the bone in the tooth socket, the socket will spontaneously heal with regeneration of the bone in the socket.  As there is a lack of evidence of a clinical defect requiring grafting and the bone socket would be expected to heal spontaneously, the dental necessity of D7953 has not been established.  Additionally, the appeal documentation does not show any indication for the requested procedure D9223, deep sedation/general anesthesia.  The literature shows risk with the service requested, and alternatives to sedation and general anesthesia are available.  In sum, dental procedure codes D7953 and D9223 are not dentally necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer is board certified in dentistry 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 level of care. Findings:  The physician reviewer found that due to the lengthy history of drinking and increased reports of consumption, a residentially-based detoxification and preliminary introduction to chemical dependency treatment was safe, appropriate and consistent with good medical practice.  However, although addiction specialty services remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting.  First, the absence of significant comorbidity supported a less restrictive setting.  The patient completed detoxification, and there was no evidence of the emergence of late alcohol withdrawal symptomatologies.  Despite the diagnosis of hypothyroidism and hypertension, the patient was medically stable.  Although she had dependent personality traits and mild depressive symptoms, the patient did not have a degree of psychiatric impairment that would necessitate a residential treatment setting.  Second, the patient embraced recovery principles and was motivated in her quest for sobriety.  She had no other addictions besides alcohol.  Aside from the failed outpatient program and a few Alcoholics Anonymous meetings, the patient had no prior history of chemical dependency treatment in a less restrictive setting, such as anti-craving medication, community programming, intensive outpatient services or partial hospitalization.  This is significant in this case for two reasons.  First, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  Second, there was no evidence to suggest that comprehensive, evidence-based services provided a less restrictive treatment setting would have been insufficient or inadequate at the time.  All told, residential treatment level of care provided was not medically indicated for the treatment of this patient. Final Result: The reviewers 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: Physician 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 Stelara 45 mg/0.5 mL, two syringes every eight weeks.  Findings:  The physician reviewer found that The submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  The Health Plan has denied the request for coverage, as Stelara is most typically dosed every 12 weeks.  In this patients case, there is no documentation as to other systemic therapies that the patient has tried and failed.  Given that she has not been treated with alternative therapies at the typical dosages and schedules, the request for increased Stelara dose is not medically indicated.  It appears that this medication may not be effective for the patient in clearing her psoriasis.  Thus, alternative treatments are medically appropriate prior to increasing the dosage of this medication that has been only partially effective.  In sum, the requested Stelara 45 mg/0.5 mL, two syringes every eight weeks is not medically indicated for the treatment of this patient. Final Result: The reviewers determined that the requested medication quantity is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheldCredentials/Qualifications: Physician 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: The parent of an enrollee has requested authorization and coverage for applied behavioral analysis (ABA) therapy. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient does not have a diagnosis of ASD. In 2010, 2013, and 2014, the patient did not meet criteria for ASD using the DSM-IV. In 2015, the diagnostic criteria changed to DSM-V. Based on DSM-V criteria many children with PDD, NOS diagnosis no longer meet the criteria for ASD. The documentation submitted for review describe difficulty with oppositional behavior, inattention and social difficulties. These symptoms are likely due to the patients learning disabilities that include her working memory and processing speed with particular difficulty in listening comprehension. She also has symptoms of ADHD. The patient has adaptive deficits, inattention, communication difficulties and slower learning. In sum, the patients symptoms are consistent with a learning disability with particular difficulty with listening comprehension. She needs visuals to help her remember what she is supposed to do next. She also has inattention, difficulty processing verbal input and remembering what she just heard. In sum, the records do not support a diagnosis of ASD and ABA therapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested therapy is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total electric bed with a low air mattress. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested equipment. The Centers for Medicare and Medicaid Services (CMS) coverage determination for hospital beds state that The physicians prescription, which must accompany the initial claim, and supplementing documentation when required, must establish that a hospital bed is medically necessary. In this case, there is a lack of documentation supporting the requested equipment. There is no documentation from a provider recommending the requested bed and air mattress. Therefore, the request for a total electric bed with a low air mattress has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician reviewer board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 residential treatment center level of care services provided. Findings:  The physician reviewer found that this patient did not meet American Society of Addiction Medicine Criteria for residential level of care.  There was no evidence of suicidality or homicidality.  The patient was medically and psychiatrically stable.   The patient showed mild post-acute withdrawal symptoms at best.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with the patient's care. The patient's home environment was sober and the patient's spouse supported necessary efforts. Although the patient continued to struggle with emotions and required further treatment to help develop coping skills and insight, this did not require the structured environment of a residential setting.  The patient could have been stepped down to an ambulatory level of care such as partial hospitalization program. 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 magnetic resonance imaging (MRI) of the lumbar spine, cervical spine, and thoracic spine. Findings:  The physician reviewer found that the records show continued pain well after the Harrington Rod placement with MRI of a previous year. The patient continues to have pain but there is no fracture seen within the thoracolumbar spine on post-accident plain films and no fracture in the cervical spine on CT exam the day of her MVA. She continues to have pain but there is still no neurological deficit or other red flag to mandate spinal imaging prior to commencement and completion of a conservative trial of management including physical therapy with documented notes and continued evaluation. All told, the requested MRI of the lumbar spine, cervical spine, and thoracic spine are not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immunoglobulin (IVIG) treatment. Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has been diagnosed with CIDP.  CIDP is autoimmune inflammatory neuropathy that is well-known to respond to IVIG.  In this patients case, it is medically appropriate to administer IVIG on intermittent basis to keep the disease process under control.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested IVIG treatment is medically indicated for the treatment of this patient. Final Result: The reviewer patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for CA125 cancer screening test.  Findings:  The physician reviewer found that the CA125 serum test is elevated in approximately 50% cases of ovarian cancer cases. The CA125 serum test is sensitive but not specific since it can also be elevated in other non-malignant conditions. However, there is significant literature on the use of CA125 in detecting ovarian cancer. Although CA125 is not the sole criterion on which to decide surgery, a pre-operative level is necessary if a patients pathology shows cancer. In addition, the post-treatment surveillance of ovarian cancer patients typically involves physical and pelvic examinations, CA125 testing at the time of clinic visits, and imaging studies as clinically indicated. All told, the requested CA125 cancer screening test is supported as medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the requested testing is medically necessary for evaluation 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 medical oncology 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 authorization and coverage for Epclusa 400 mg  100 mg for 12 weeks. 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. This applies regardless of fibrosis stage. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2 trials for Epclusa, which showed superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa 400 mg  100 mg for 12 weeks 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 physician 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 reimbursement for Cologuard testing. Findings:  Three physician reviewers found that the Cologuard test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The limited evidence for Cologuard reports that 154 persons would have to be screened to find one cancer using colonoscopy, versus 166 persons using Cologuard, raising concern that Cologuard may have not detected cancer. The evidence of the impact of Cologuard on patient care or health outcomes is lacking. There is not a consensus in clinical guidelines and clinical literature to support that Cologuard has a positive impact on health outcomes. Although Cologuard is able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop. Additionally, health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer. For these reasons, Cologuard testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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.