Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested an injection of neurolytic substance for treatment of his medical condition. Nature of Statutory Criteria/Case Summary:   Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Helm and colleagues conducted a systematic review with 15 studies identified and selected for review.  The authors concluded that there is fair evidence that percutaneous neurolysis is effective in relieving low back and/or leg pain due to post lumbar surgery syndrome or spinal stenosis.  Amaral and colleagues concluded that the application of morphine sulfate in a single epidural dose was shown to be a good technique for pain therapy following lumbar spinal surgery.  The aggregate of evidence-based medical literature supports this request for analgesia/pain management.  Epidural morphine (Duramorph) for postoperative pain control was medically appropriate as the medication was indicated and use was consistent with current medical standards.  All told, injection of neurolytic substance was likely to have been of greater benefit than other treatment options. Final Result:  two reviewers  determined that the services at issue were 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:  All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested authorization and coverage for cervical artificial disc procedure for treatment of her medical condition. The physician reviewer found that according to the documentation submitted for review, this patient has degeneration of multiple cervical levels on magnetic resonance imaging and has been treated with multiple conservative measures. However, a one-level cervical total disc replacement is contraindicated because the patient has MRI evidence of more than one level of cervical degeneration. Moreover, the surgery is not likely to relieve the patients neck pain. Therefore, the request for cervical artificial disc is not likely to be more beneficial for the patient's medical condition than any other available standard therapy. Final Result: The reviewer determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The physician reviewer found that rhe 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient has not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  In reviewing the clinical documentation, the partial hospitalization services remain medically indicated and consistent with good medical practice.  Further, the services are reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, partial hospitalization program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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 (residential) chemical dependency treatment program services for treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Addictive disorders are chronic, lifelong, relapsing conditions which may require inpatient episodic treatment in more restrictive settings over the course of the illness.  In this case, the patients drug use dominates all functional domains.  He has has serious health problems, many of which are at least partially due to his drug use.  He has been unable to refrain from drug use despite the outpatient treatment plan developed with his provider, which stated a higher level of care would be considered if unsuccessful.  Based on the clinical records, effective, adequate treatment cannot be reasonably provided in the outpatient setting at this time.  All told, the requested inpatient (residential) chemical dependency treatment program services are medically indicated 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 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 Harvoni for 12 weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 or viral load.  Per the guidelines, non-cirrhotic, treatment-experienced, 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 hepatitis C, genotype 1 regardless of fibrosis stage.  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 AmniSure testing for evaluation of her premature labor. Findings:  Two physician reviewers found that AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. The study by researchers found AmniSure to be highly accurate in diagnosing fetal membrane rupture. In this case, nitrazine and fern testing was not available. Since other standard testing was not available, the AmniSure testing 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 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 reviewers are board certified in obstetrics and gynecology 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 Harvoni for 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Per AASLD/IDSA guidelines Harvoni for 12 weeks is recommended for treatment-naive patients with HCV genotype 1 infection. Therefore, Harvoni should be approved as 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous tibial nerve stimulation treatments for treatment of his medical condition.  Findings:  Three physician reviewers found that while percutaneous tibial nerve stimulation is an acceptable third line therapy for symptoms of overactive bladder unresolved by standard therapies and has been shown in some series of female patients to approach equal efficacy at one year for those who respond, there is no evidence that it exceeds efficacy of standard treatment, particularly in the male patient.  Although this treatment is approved for use in patients who have failed standard approaches, the long-term efficacy in controlled prospective study inclusive of an observational arm is lacking.  All told, the superior efficacy of the services at issue has not been established. Final Result: Three reviewers concluded that the services at issue were not and are not likely to be more beneficial for treatment of your medical condition than any available standard therapy; the Health Plans denial has been upheld. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in urology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral knee replacements for treatment of his osteoarthritis of the knees.  Findings:  The physician reviewer found that in this case, the patients age exposes him to long term complications of an increased revision rate. The presence of severe obesity makes a total knee arthroplasty with good, soft tissue technique more difficult to achieve and increases the risk of postoperative infection. Elevated blood pressure is an issue which should be addressed prior to the planned surgery. In sum, delaying surgery in order to address the issues of severe obesity and elevated blood pressure will likely decrease the incidence of significant complications after surgery. For the above described reasons, the surgical approach would best be postponed to address the medical issues present. As such, the request for bilateral knee replacements has not been established as medically necessary in this clinical setting. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 or viral load.  Per the guidelines, Sovaldi and Daklinza for 12 weeks is first-line therapy in treatment-naive genotype 3 patients.  This patient is interferon-ineligible due to psoriasis, which can be exacerbated by interferon.  All told, the requested Sovaldi and Daklinza for 12 weeks are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medications 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 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 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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 or viral load.  For treatment-naive patients with genotype 4, the guidelines recommend treatment with daily Harvoni for 12 weeks.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for 16 weeks for treatment of his chronic hepatitis C virus genotype 2.  Findings:  The physician reviewer found that according to the most 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 or viral load. This patient has FibroSure and laboratory testing consistent with cirrhosis. Per the AASLD/IDSA guidelines, patients with cirrhosis are high priority for therapy. Per guidelines, cirrhotic genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 16 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 hepatitis C genotype 2 regardless of fibrosis stage. The guidelines reflect the FUSION trial, which showed higher efficacy with 16 rather than 12 weeks of treatment. For these reasons, the requested treatment with Sovaldi and ribavirin for 16 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a cervical total disc replacement utilizing the Mobi-C artificial cervical disc for treatment of her disc degeneration with stenosis.  Findings:  Two physician reviewers found that the request for cervical total disc replacement utilizing the Mobi-C artificial cervical disc is not likely to be more effective for this patient than other available options. There is a lack of adequate studies in the peer-reviewed literature supporting multi-level disc replacement. A study by researchers reviewed the data concerning the role of cervical arthroplasty in reducing adjacent-level degeneration. The authors concluded, Adjacent-level degeneration has not been adequately studied in a review of the available randomized controlled trials on this topic, and there is no clinical evidence of reduction in adjacent-level degeneration with the use of cervical arthroplasty. Moreover, cervical disc replacement is indicated in single-level degenerative disc disease. In this case, the patient has multi-level degenerative disease. In addition, long-term, adverse effects of arthroplasty materials, such as metallic and polymeric debris, are not known at this time. For the reasons provided, the requested procedure is not likely to be more beneficial for the patient's medical condition than any other available standard therapy. Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the walk aide, functional electrical stimulator (FES) HCPCS A4595 (TENS suppl 2 lead per month) and HCPCS E0770 (FES NOS) for treatment of her multiple sclerosis.  Two physician reviewers found that the walk aide or functional electrical stimulation (FES) device is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Cameron and Wagner wrote FES for foot drop reduces energy consumption and improves walking speed, distance, and efficiency in people with MS. The patient has used the walk aide and noted such improvement in walking distance. In another study of the use of FES and ankle foot orthoses for gait abnormalities in multiple sclerosis, Bulley and colleagues state On balance, the impacts of the devices [FES and ankle foot orthoses] on improving activities and participation were more important for participants than practical barriers, highlighting the importance of combining understanding of individual experiences and preferences with clinical decision-making when prescribing a device to manage foot-drop.  Given the functional gains of utilizing walk aide and the patients reported functional benefits with the walk aide device, the requested device is likely to be more beneficial for treatment of her condition than any available standard therapy.   Final Result: Two reviewers determined that the requested device 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: One reviewer is board certified in physical medicine and rehabilitation and is actively practicing.  Two reviewers are board certified in physical medicine and rehabilitation and neuromuscular medicine 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.