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 Zepatier 50-100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1b patients should be treated with regimens including or Zepatier for 12 weeks, based on clinical trial results showing a 99% cure rate regardless of NS5A resistance. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:Nature of Statutory Criteria/Case Summary:Findings:  The physician reviewer found that buprenorphine has been approved for use in the United States for the treatment of opioid use disorder, and today is a leading treatment modality in efforts to combat the burgeoning opioid epidemic. Buprenorphine comes in several preparations: Subutex sublingual (buprenorphine mono-tablet), Suboxone sublingual tablet and film strip (buprenorphine-naloxone combination), Bunavail (buprenorphine-naloxone buccal film), Buprenex (buprenorphine injectable) and Butrans (buprenorphine transdermal patch).  The medical record indicates the patient has been regularly attending clinic appointments. Per the documentation, Suboxone sublingual tablets have been poorly tolerated, resulting in nausea, congestion and both numbness and paresthesia of the extremities. Thus, the provider has recommended Suboxone film, and this medication is safe and appropriate when taken as prescribed. There is sufficient support for the requested medication in this clinical setting. All told, the requested Suboxone 8-2mg film is medically necessary 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 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 reimbursement and prospective authorization and coverage for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients abuse of opiates, benzodiazepines and cannabinoids use was impairing his daily routine and contributed to significant impairment across multiple domains of functionality. The patient was unable to sustain employment and lost his apartment.  His motor vehicle license had been revoked due to substance use.  He was prescribed psychotropic medications including an atypical antipsychotic. This patient had reportedly tried buprenorphine prior to the episode of care, although the documentation did not specify if it was obtained illicitly or by prescription. Upon presentation, the patient was malnourished, circumstantial, anxious, agitated and depressed.  He endorsed symptoms consistent with a withdrawal syndrome.  Finally, despite outpatient services and a brief residential stay during the episode of illness, the patient was unable to maintain sobriety in his environment.  The patient was clinically unstable and had not consolidated the treatment gains necessary to succeed in the outpatient setting and promptly would have relapsed in a community based setting if he was not admitted that day. However, the patient had positive support from this patients family and a recent three and half year history of sobriety. The patient also has prior success with community programming. The documentation supports that 2 weeks of services were medically necessary.  The two weeks of treatment would have been reasonably expected to improve this patients condition and prevent a more serious episode of illness while fulfilling the initial projected length of stay and providing a total of four weeks of residential treatment, which would be a duration of care consistent with community standards. For these reasons, a portion of the residential treatment center services was medically necessary for treatment of this patients medical condition. Specifically, the residential treatment center services for 2 weeks were medically necessary, but not thereafter. Final Result: The reviewer determined that the services at issue was 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency medical services. Findings:  The physician reviewer found that the medical services provided were necessary for treatment of a psychiatric emergency medical condition. An overdose has potential for loss of consciousness, tachycardia, prolongation of the QT interval, and hypokalemia with first degree atrioventricular block. In this case, the patient presented with altered mental status that did not reverse with Narcan. The patient had history of depression with psychotic features, which is a difficult diagnosis to treat and is associated with an elevated rate of suicide. The patient admitted to taking an overdose with suicidal intent. The patient was not cooperative with the initial psychiatric evaluation. The patient was placed on an involuntary psychiatric hold. The patient was also being evaluated for a possible blood clot. Considering the patients psychiatric diagnosis, reluctance to engage in a therapeutic discussion, and the patients need for further medical assessment to rule out potentially life-threatening conditions, the services at issue met the criteria for emergency services as defined above. Final Result: The reviewer determined that the patient received psychiatric emergency medical services on the dates of service at issue. 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: The patients parent has requested reimbursement for the cranial molding helmet provided. Findings:  The physician reviewer found that In the medical literature, a study  noted that the severity of skull deformation was quantified using the oblique diameter difference index and the cranioproportional index (CPI) of plagiocephalometry. The oblique diameter difference index provides the degree of the plagiocephalic component of skull deformation and is the ratio between the longest cranial diagonal and the shortest cranial diagonal multiplied by 100%, with both located at 40 degrees from the anterior-posterior line. This patients oblique diameter difference index was 108%, which is consistent with moderate deformation. In addition, cut off points used to measure the degree of skull deformity must take into account more than just the CPI as demonstrated by a study. In most cases, positional plagiocephaly can be treated by change in positioning . However, there is Class I evidence from a single study and Class II evidence from several studies that repositioning is inferior to physical therapy and to use of a helmet, respectively. According to the Congress of Neurological Surgeons, helmet therapy is recommended for infants with persistent moderate to severe plagiocephaly after a course of conservative treatment (repositioning and/or physical therapy). This patient presented with moderate deformity in terms of oblique diameter difference index, coupled with the failure of more conservative measures including repositioning, the cranial molding helmet provided was medically necessary for the patients medical condition. Final Result: The reviewer determined that the device at issue was 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for epidural injections for treatment of the enrollees low back pain. Findings:  The physician reviewer found that there is support in the medical literature as well as in the documentation for the requested services in this clinical setting. Epidural injections appropriate when patients have persistent radicular pain that has not been responsive to conservative care for at least six weeks; the patient has stable medical condition; the previous epidural was successful; and it has been more than seven days since the last epidural with a maximum of four injections in 12 months. In this patients case, the patient has radicular pain. The records show nerve impingement that corresponds to this patients symptoms. The documentation also indicates that this patient has not responded to at least six weeks of conservative care with no unstable medical conditions noted. The patient has reported that his radicular pain interferes with activities of daily living and previous epidural was successful. Furthermore, the patient is doing physical therapy regularly. 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 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: An enrollee has requested authorization and coverage for H.P. Acthar injection for treatment of the enrollees nephrotic syndrome with focal segmental glomerular sclerosis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested medication. According to research Current first-line anti-proteinuric treatments for nephrotic syndrome (NS) do not produce an effective response in all patients and are not tolerated by some patients. Additional effective and tolerable treatment options in NS are strongly needed. The authors examined Acthar gel in patients with varied-etiology NS. The authors concluded that Acthar gel may meet an important treatment need in patients with treatment-resistant NS in response to first-line therapies, patients unable to tolerate first-line therapies, and in patients with advanced disease. In this case, the patient has failed first-line therapy and is at a high risk for renal replacement therapy due to need proteinuria and reduced renal mass. 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 nephrology 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 reimbursement for MyRisk genetic testing for evaluation of the enrollees risk of cancer. Findings:  Two physician reviewers found that if the patient tested negative for BRCA1 it could be possible that other non-tested affected family members harbored a different mutation or that a mutation came from the patients paternal side. A negative panel affects how the patient will be screened in the future. The patient would revert back to the same risk as the general population and no additional cancer screening would be necessary.  The recent introduction of multi-gene testing for hereditary forms of cancer has rapidly altered the clinical approach to testing at-risk patients and their families. Based on next-generation sequencing technology, these tests simultaneously analyze a set of genes that are associated with a specific family cancer phenotype or multiple phenotypes. When more than one gene can explain an inherited cancer syndrome, then multi-gene testing may be more efficient. Final Result: The reviewers determined that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:The parent of an enrollee has requested authorization and coverage for clinical/whole exome sequencing (WES) for evaluation of the enrollees alopecia universalis.  Findings:  Two physician reviewers found that WES has been endorsed by the American College of Medical Genetics and Genomics, which states that WES should be considered in the clinical diagnostic assessment of a phenotypically affected individual when: The phenotype or family history data strongly implicate a genetic etiology, but the phenotype does not correspond with a specific disorder for which a genetic test targeting a specific gene is available on a clinical basis; a patient presents with a defined genetic disorder that demonstrates a high degree of genetic heterogeneity, making WES or WGS analysis of multiple genes simultaneously a more practical approach; A patient presents with a likely genetic disorder but specific genetic tests available for that phenotype have failed to arrive at a diagnosis. Based on the clinical documentation submitted for review, the patient meets these criteria. In this case, the proposed testing is supported by the strong genetic underpinnings of alopecia areata, the polygenic nature of the condition, the presence of clinically relevant conditions that can present with alopecia areata, and that WES is clinically useful and has evidence based support in the peer-reviewed literature. Final Result: The reviewers determined that the requested testing is 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: Reviewers 1, 2 and 3 are board certified in pediatrics and clinical genetics 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: An enrollee has requested authorization and coverage for Epclusa 40/100 mg tablets for 12 weeks for treatment of the enrollees hepatitis C virus. 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 in all cases, regardless of fibrosis stage. In this case, there is imaging evidence of cirrhosis. Per the guidelines, Epclusa is recommended as first line therapy for treatment naive, non-cirrhotic patients with all genotypes of hepatitis C, based on the results of the ASTRAL series of trials. Delay in treatment may result in decreased survival. 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 authorization and coverage for Epclusa for 12 weeks for treatment of the enrollees hepatitis C. 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, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment-naive, genotype 2 patients. A delay in treatment may result in decreased survival. Final Result: The reviewer determined that the requested medication regimen 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 authorization and coverage for lumbar spinal fusion surgery for treatment of the enrollees low back pain. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting. Researchers reviewed lumbar spinal fusion performed for chronic low back pain due to degenerative disc disease. A total of 3,060 patients were reviewed. The authors concluded that the body of literature supports fusion surgery as a viable treatment option for reducing pain and improving function in patients with chronic low back pain refractory to nonsurgical care when a diagnosis of disc degeneration can be made. The authors noted that substantial improvement can be expected in patients with chronic low back pain and degenerative disc disease with a fusion. In this case, there is evidence of degenerative disc disease at L4-L5 with moderately severe loss of height. There is sufficient support for the requested services in this clinical setting. All told, lumbar spinal fusion surgery is medically necessary for the treatment of this patient. 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 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.