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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested facet ablation and epidural injections for treatment of her low back pain.  Findings:  The physician reviewer found that facet ablation and epidural injections are not medically necessary for treatment of this patients medical condition. The peer-reviewed medical literature does not support a series of epidural steroid injection in treating the patients medical condition. Two authors performed a literature review to determine the current evidence to support guidelines for frequency and timing of epidural steroid injections and to help determine what sort of response should occur to repeat an injection, and to outline specific research needs in these areas. The authors concluded There does not appear to be any evidence to support the current common practice of a series of injections. Moreover, the medical literature indicated that there was moderate evidence for interlaminar epidurals in the cervical spine and limited evidence in the lumbar spine for long-term relief. Given that the patient did not experience long-term relief, or demonstrate reduced use of medications and adjunctive therapy (physical therapy, heat and ice) with the previous epidural steroid injection, a repeat epidural steroid is not medically necessary. In addition, the patient had a medial branch block, and there was no follow-up note showing the patient had a positive diagnostic block. Facet radiofrequency ablation is indicated in patients with positive diagnostic blocks. For the reasons provided, the request for facet ablation and epidural injections is not medically necessary for treatment of the patients medical condition. 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 anesthesiology and 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 a specific number of hours per month of applied behavior analysis (ABA) therapy, a specific number of hours of supervision and a specific number of hours of parental training sessions per month for treatment of the enrollees autism spectrum disorder. Findings:  Two physician reviewers found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Per the documentation provided, the patient began attending college.  There is a lack of research regarding individuals who are able to attend college requiring or benefitting from ABA therapy.  Further, there is a lack of data regarding the use of ABA therapy to teach coping skills.  However, it is not appropriate to abruptly discontinue services in this clinical setting.  In this patients case, the requested amount of hours per month of ABA therapy, the requested amount of hours of supervision and the requested amount of hours of parent training sessions per month were appropriate initially.  However, decreasing the number of hours of ABA therapy per week was appropriate.  It is appropriate to gradually discontinue ABA therapy while starting a social skills group and individual counseling for coping skills.  Thus, a portion of the services at issue was and is medically indicated for the treatment of this patient.Final Result: Two reviewers determined that a portion of the services at issue was and is 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing.  One reviewer is board certified in neurology with special qualifications in child neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested or cervical facet joint injections for treatment of his neck pain with right upper extremity radiculopathy.   Findings:  The physician reviewer found that the patients complaints and imaging findings are not amenable to treatment via cervical facet injections. The patient has a disc complex with cord compression. A facet injection would not provide any benefit in this clinical setting. Facet injections are useful for treating facet joint disease of the spine and can be helpful in alleviated axial neck pain without radiculopathy. The standard of care in this patients circumstance includes cervical epidural steroid injections and not cervical facet injections. Thus, the requested cervical facet joint injections are not medically necessary for treatment of this patients medical condition. 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 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: An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  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 or viral load. Per guidelines, 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 genotype 1 hepatitis C regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as 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 Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on HCV does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. A report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia (CPT 00810) during a colonoscopy for evaluation of his risk for colon cancer. The physician reviewer found that the patient was noted to have ASA II medical status. In the medical literature, Hausman and Reich noted that since esophagogastroduodenoscopy (EGD) and colonoscopy are relatively non-invasive, of short duration, and not associated with either fluid shifts or significant post-procedure discomfort.  In appropriate patients, these procedures are well-suited to office-based practice.  Given this patients ASA II status, the anesthesia (CPT 00810) during the colonoscopy was not medically necessary. Final Result: The reviewer determined that the services at issue were 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 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: An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1b.  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 or viral load. Per guidelines, 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 genotype 1 hepatitis C regardless of fibrosis stage. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as 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 Flovent HFA 220 mcg for treatment of his eosinophilic esophagitis. The physician reviewer found that according to Goldin and Chan eosinophilic esophagitis (EoE) is an increasingly diagnosed, immune-mediated disease characterized by inflammation of the esophagus. Adults typically present with dysphagia and a history of food impaction. The authors further state that Effective treatment of EoE requires a multidisciplinary approach with gastroenterologists, pathologists, allergists, and nutritionists. Treatments include elimination and elemental diets, topical glucocorticoids (fluticasone and budesonide), and endoscopic dilation. In addition, the van Rhijn and colleagues state Fluticasone propionate treatment decreases eosinophilic inflammation and improves the esophageal mucosal barrier integrity in adult EoE patients. Improvement of the mucosal barrier integrity correlates with normalization of expression of desmoglein-1 and filaggrin marker genes. Based on the peer-reviewed literature and clinical documentation submitted for review, the requested medication is medically necessary for treatment of the patients EoE.  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 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 12 weeks for the treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines indicate that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The guidelines support Harvoni for 12 weeks for patients with hepatitis C, genotype 6 infection who have failed prior treatment with peg-interferon and ribavirin.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. 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 breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 residential treatment center level of care for substance abuse for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patient had concerning psychiatric symptoms and severe addictive illness.  Further, he failed to achieve sobriety after a truncated residential stay during the episode of illness.  He was drinking and had a history of alcohol withdrawal seizures.  Prior to admission, he was unemployed, psychiatrically distressed and did not have a support network conducive to recovery.  Based on these factors, residential placement was reasonably expected to improve the patients condition.  The structure and supervision of the residential facility afforded opportunity for a benzodiazepine taper, serial psychiatric evaluation, exploration of developmental traumas, introduction to chemical dependency counseling and after-care planning.  The residential level of care was safe, appropriate and consistent with good medical practice.  All told, residential treatment center level of care for substance was 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient hospital services for treatment of his atrial fibrillation.  The physician reviewer found that according to Ganz, patients with atrial fibrillation and a rapid ventricular response who are symptomatic but not unstable, initial therapy usually involves intravenous rate control medications. Patients who are chronically managed with a rhythm control strategy can undergo cardioversion if they have been adequately anticoagulated or are considered to have a low thromboembolic risk. In this case, the patient was admitted with COPD and cor pulmonale. The patient was initially noted to have atrial fibrillation with rapid ventricular response. He required an intravenous drip of diltiazem for rate control.  Adequate control was not immediately obtained on oral medications. Subsequently, the patient could have been discharged to a lower level of care. As such, initial inpatient hospital services were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in internal 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:  The parent of an enrollee has requested residential behavioral health treatment for treatment of the enrollees obsessive compulsive disorder (OCD). Findings:  The physician reviewer found that the records indicate that this patient has recently completed an extensive stay at a residential treatment center. As part of treatment, she underwent medication management, extensive psychotherapy treatment including exposure and response prevention, and flooding therapy for OCD. However, there is a lack of evidence of objective functional improvement after treatment. All told, the requested residential behavioral health treatment level of care is not medically necessary for treatment of this patients medical condition.   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 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.