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 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. For these reasons, Epclusa for 12 weeks is medically necessary for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The enrollee has requested authorization and coverage for 135 hours per month of one-on-one applied behavioral analysis (ABA) therapyfor treatment of the autism spectrum disorder.  Findings:  The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patients behavior has improved with a decrease in non-compliance and inflexibility. Tantrums, elopement and aggressive behaviors have been eliminated. Services have been redirected to focus on social and communication skills, aiming to decrease inflexibility, perseveration and passive non-compliance. There is a lack of documentation demonstrating a consistent decline or regression in function during the patients ABA fade out plan. The patients behavioral concerns are predominantly with social skills and the records do not demonstrate that the patient is displaying behavior that is dangerous to himself or to others. For the reasons provided, the request for 135 hours per month of one-on-one ABA therapy has not been established as medically necessary. 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 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 advanced lipoprotein testing for evaluation of the enrollee who presented to her provider for examination.Findings:  The physician reviewer found that the patient had advanced lipoprotein analysis as part of a medical evaluation for lifestyle alterations. The values obtained showed increased cholesterol as well as abnormal values on the sub-fractions such as low density lipoprotein particle count. The patient has requested reimbursement for advanced lipoprotein testing. The Health Plan denied this request for reimbursement and reported that the services at issue were investigational for the evaluation of this patients medical condition. There is insufficient data to support the use of advanced lipoprotein testing in this clinical setting. While some researchers have advocated use of advanced lipoprotein testing for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the American College of Cardiology (ACC) guidelines do not support the use of advanced lipoprotein testing. Rather, their guidelines recommend use of standard risk factors and standard lipid profile to make decisions about lipid management. In addition, the guidelines have moved away from specific target values and emphasize use of the pooled risk score analysis for decisions regarding statin therapy. Therefore, the advanced lipoprotein testing was not likely to have been more beneficial than the standard testing options for the evaluation of this patient.Final Result: All three 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number two is board certified in internal medicine with sub-specialty certification in cardiovascular 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.Physician reviewer number three is board certified in internal medicine with sub-specialty certification in cardiovascular 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 the patient has requested reimbursement for the residential treatment services provided for treatment of the enrollees behavioral health issues. Findings:  The physician reviewer found that to objectively determine the appropriate level of care for the patient, the case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). On admission, the patient was at significant risk of harm (score 3) with a recent suicide attempt by overdosing on Prozac. Per documentation, the patient is impulsive and has an all or nothing mind frame and is either feeling better or suicidal and depressed. The patient demonstrated moderate functional impairment (score 3) since although she is intelligent and doing well in school, she has some moderate impairment when she will feel overwhelmed due to normal psychosocial stressors. The patient presented with significant co-morbidity (score 3) with major depressive disorder, generalized anxiety disorder, social (pragmatic) communication disorder, and premenstrual dysphoric disorder. However, the patient did not have any medical problems which required 24-hour monitoring. The patient had a mildly stressful recovery environment (score 2), which was supportive (score 2), and the patient had demonstrated equivocal resiliency and response to treatment (score 3). The patient has been constructive in treatment (score 2) and is described as cooperative and friendly. This gives the patient a composite score of 18, which is consistent with intensive outpatient program (IOP). Thus, the patient could have been treated in a less restrictive environment. This is consistent with the recommendations of the provider to treat the patient with more structure and biweekly therapy, yet allowing the patient to be treated in a less restrictive environment. The patient continued to need treatment for her depression and anxiety, but this could have been done in a less restrictive environment. Therefore, the residential treatment services provided were not medically necessary and that the patient could have been treated in a less restrictive environment. 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for fentanyl patch 50 mcg for treatment of the enrollees chronic nerve pain.  Based on the documentation submitted for review, fentanyl patch 50 mcg has not been established as medically necessary for treatment of the patients medical condition. The requested dosage and quantity are indicated for malignant pain. The medical records show the patient has chronic non-malignant pain. The current standard of care for chronic nerve pain is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. There are a variety of anti-convulsants and anti-depressants considered adjunctive to pain management therapy. Therefore, based on current medical literature and in consideration of the presented clinical records, fentanyl patch 50 mcg is not medically necessary for treatment of the patients medical condition.  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 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: The patient has requested reimbursement for the contrast-enhanced coronary computed tomography angiography (CPT 75574) for evaluation of the enrollees heart disease status post chemotherapy for sarcoma. Findings:  The physician reviewer found that this patient has a rare primary malignant tumor arising in his heart. The current medical literature advocates the use of CT, magnetic resonance imaging (MRI), and transesophageal echocardiography in staging and surveillance after resection. In this case, the resection was subtotal indicating positive margins were left at surgery likely related to the difficulty in resecting this type of mass given the vital structures which are contiguous and/or inseparable from the mass. The coronary arteries are sensitive to the effects of radiation therapy and in order to deliver the radiation dose as safely as possible, the location and anatomic variants of the coronary circulation must be assessed prior to radiation therapy and then assessed after treatment in order to stratify risk. For these reasons, the contrast-enhanced coronary CT angiography (CPT 75574) was medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that the diagnostic procedure at issue was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage of promethazine with codeine syrup for treatment of the enrollee who has a history of chronic asthma.Findings:  The physician reviewer found that there is a lack of support in the documentation provider for the medical necessity of the requested medication. The medical literature recommends caution when prescribing opioids at any dosage. In this patients case, the record indicates that this patient is already taking daily opiates for chronic pain syndrome. The U.S. Food and Drug Administration (FDA) approved promethazine codeine syrup for temporary relief of cough due to the common cold or allergy. The intent for its approval was to provide short-term treatment for a cough. Additionally, the FDA did not approve promethazine with codeine syrup for daily use of a year or more as requested in this patients case. Accordingly, additional opiates may place this patient for a high potential of abuse. As such, the use of promethazine with codeine syrup is not medically necessary for treatment of this patients medical condition.] 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 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.
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 for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the documentation submitted does not support the medical necessity of the services at issue in this clinical setting. The patient participated in groups, individual therapy, family sessions, and other treatment modalities.  The patient denied suicidal or homicidal ideation. The patients mood was lethargic.  The patients affect was flat but indicated that the migraine medication made the patient feel spacey. The patients memory and concentration were intact, as were insight and judgment. The patient demonstrated insight and was working on the ability to speak up and set boundaries. The patient had ongoing depression, anxiety, some feelings of hopelessness and difficulty motivating.  She had the ongoing fear of being unable to manage at home.  The patient presented to the patients session looking slightly disheveled. The patient indicated that was due to lack of self-care in lieu of caring for others.  The patient had ongoing migraines. Sleep was still disrupted at five hours a night and the patient reported ongoing PTSD symptoms of nightmares, flashbacks, and hypervigilance. The patient denied suicidal ideation, and she was not a danger to others.  The records show that the patient actively participated in all treatment modalities. The patient gained insight.  Although the patient continued to endorse ongoing symptoms of depression, anxiety, and PTSD, this appears to be the patients baseline. Moreover, the medication changes performed were not drastic in nature and not requiring a residential setting.  The patients parents and fiance were supportive.  The patient no longer required 24 hours per day seven days per week of monitoring in a residential setting. Based on the documentation provided, the patient could have been stepped down to a lower level of care. Therefore, residential treatment level of care was not medically necessary for the treatment of this 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 with sub-specialty certification in addiction 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genetic screening (MyRisk) for evaluation of the enrollees risk of cancer.Findings:  The physician reviewer found that the genetic screening (MyRisk) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The MyRisk panel testing is considered a standard of care for patients in this clinical setting. The patients father appears to be unavailable for testing and had colon cancer and a brain tumor younger than age 50 increasing the patients risk of Lynch syndrome. The MyRisk panel detects disease-causing mutations in the MLH1, MSH2, EPCAM, MSH6, PMS2 and MYH genes that are responsible for the majority of Lynch syndrome and MYH-associated polyposis (MAP) cases. A positive test would allow risk reducing screening and decrease in the patients cancer risk. Based on the clinical documentation submitted for review, the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for genetic cancer susceptibility panel testing for evaluation of the enrollees carcinoma of the small bowel.  Findings:  Two physician reviewers found that the diagnosis of small intestine tumors is often made in late stage due to typically non-specific symptoms at time of presentation. In recent years with the wide use of next generation technology to assess the molecular profile, multi-gene analysis has become more efficient. Current practice is to assess the molecular profile in order guide the choice of standard and novel therapeutic options. In colorectal cancer, the presence of KRAS, NRAS, and BRAF mutations direct standard therapy options. The presence of a RAS mutation, limits the utility of standard therapies. Due to the rarity of the tumor, evaluation of patients for clinical trials is recommended and screening necessitates tumor molecular analysis. For this reason, the use of next generation sequencing based multi-gene panel testing is clinically indicated to evaluate the treatment options available to this patient given the rarity of her tumor.  Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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.