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

Nature of Statutory Criteria/Case Summary: An enrollee has requested laboratory testing for liver scar tissue (fibrosis)  CPT code 81599 unlisted Maaa for evaluation of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that noninvasive testing for fibrosis is accepted by national guidelines to assess the stage of fibrosis to be treated for HCV. Although liver biopsy is the diagnostic standard, sampling error and observer variability limit test performance, particularly when inadequate sampling occurs. In addition, the liver biopsy is invasive and minor complications are common, limiting patient and practitioner acceptance. Serious complications such as bleeding, although rare, are well recognized. Recently, noninvasive tests to stage the degree of fibrosis in patients with chronic HCV infection include models incorporating indirect serum biomarkers (routine tests such as aspartate transaminase (AST), alanine transaminase (ALT), and platelet count), direct serum biomarkers (components of the extracellular matrix produced by activated hepatic stellate cells) and vibration-controlled transient liver elastography. Therefore, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were 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 internal medicine with sub-specialty certification in gastroenterology 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 16 sessions of aqua therapy for treatment of her medical condition.   The physician reviewer found that the requested therapy is not medically indicated for the treatment of this patient. In this case, the patient has normal bilateral upper extremity strength which is required for continued independent functioning. Based on the documentation submitted for review, there has been no functional benefit with the patients prior aquatic treatments and there is no functional benefit expected with the treatments being requested. The patient can maintain her upper extremity strength through continued wheelchair use and, if needed, with a home exercise program using conventional equipment. Additional skilled aquatic therapy sessions are not medically necessary for the 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 reviewer is board certified in physical medicine and rehabilitation 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 compounded hydrocodone for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  Researchers reported that high-dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Researchers also reported that prolonged use of high-dose opiates might induce tolerance and abnormal pain sensitivity.  All told, the requested compounded hydrocodone is not medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested patent foramen ovale closure surgery for treatment of her medical condition. Findings:  Two physician reviewers found that the request for patent foramen ovale closure surgery is not likely to be more effective for this patient than other available options. This issue has been the subject of many investigations over a long period of time. Although it seems reasonable that correction of a patent foramen ovale would reduce the subsequent risk of recurrent stroke, evidence to establish a clear benefit is not conclusive and superiority to medical therapy has not been shown. Other causes for stroke sometimes are found over time after an initial conclusion that the patent foramen ovale was responsible. In sum, the requested closure of patent foramen ovale is not likely to be more beneficial for treatment of the patients medical condition than 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 internal medicine with sub-specialty certification in cardiovascular disease 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 Jublia medication for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Jublia is U.S. Food and Drug Administration (FDA) approved for the topical treatment of onychomycosis of the toenails due to Trichophyton rubrum and Trichophyton mentagrophytes.  This patient has failed treatment with antifungal medications, topical laser treatments and topical antifungal treatment.  Therefore, Jublia medication 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 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 treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that as per the medical guidelines, all patients with virologic evidence of chronic HCV infection, except for those with limited life expectancy of less than 12 months due to non-related conditions, should be considered for treatment. Candidacy for treatment is limited mainly by the presence of contraindications to the available regimens. Harvoni is a Class 1, level A recommendation. Therefore based on the guidelines Harvoni is appropriate and medically necessary. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that per the nationally recognized treatment guidelines there are several options with similar efficacy recommended for treatment-naive patients with HCV genotype 1a infection. Daily Harvoni for 12 weeks (Class I, Level A), daily Viekira Pak and weight-based ribavirin for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) (Class I, Level A) and daily Sovaldi plus Olysio with or without weight-based ribavirin for 12 weeks (no cirrhosis) or 24 weeks (cirrhosis) (Class IIa, Level B). The Health Plans formulary option of Viekira Pak and ribavirin is equally efficacious and as highly recommended per the medical guidelines as is the requested Harvoni. In this patients case, the documentation submitted for review does not support an absolute contraindication of the use of the Health Plans formulary of Viekira Pak and ribavirin. As such, the request for Harvoni is not medically necessary given the Health Plans authorization of Viekira Pak for treatment of the patients HCV which has identical rating and equivalent efficacy per the medical guidelines. 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 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 magnetic resonance imaging (MRI) of the lumbar spine for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The clinical documentation submitted for review does not demonstrate focal weakness, sensory changes or abnormal reflexes on physical examination. There is no documentation supporting an abnormal electromyography (EMG) test in the setting of radicular symptoms. Moreover, there is a lack of documentation demonstrating the patient has trialed six weeks of conservative therapy without evidence of improvement.  Based on the medical literature and clinical documentation provided, the request for MRI of the lumbar spine is not medically necessary for evaluation 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 diagnostic radiology with sub-specialty certification in interventional 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 partial hospitalization treatment for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation does not support the services at issue in this clinical setting.  This patient has completed courses of partial hospitalization and presented with a familiar symptom complex.  Thus, the expectation for enduring improvement and prevention of a more serious episode with another iteration of partial hospitalization is dubious.  Further, the clinical documentation does not demonstrate that a subsequent well-organized and comprehensive outpatient plan had been unsuccessful following the most recent discharge from partial.  In this patients case, there is no evidence that a multidisciplinary intensive outpatient plan including daily group therapies with community psychosocial support programming coupled with case management services, suicide prevention safety planning, psychiatric visits and individual therapy sessions would have been insufficient.  Based on the relevant peer-reviewed literature and documentation provided, partial hospitalization treatment was not and is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not and 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 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 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.  This recommendation is based on high-quality clinical trial data.  All told, the requested treatment with Harvoni 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested psychiatric services on an emergent or urgent basis.  Findings: The physician reviewer found that based on the documentation submitted for review, the patient was not experiencing a psychiatric emergency medical condition as she was not in immediate danger to herself or others or unable to utilize, food, shelter, or clothing due to her mental disorder. The patient was not endorsing symptoms of suicidal or homicidal behavior, she was not psychotic, and she was able to perform all her activities of daily living. However, it has been established that criteria for urgently needed services were met. In this case, the patient stepped down from acute level of care to partial hospitalization program (PHP) level of care. The record from the patients acute inpatient admission prior to this date indicates that the patient was feeling very stressed, anxious and depressed.  The discharge summary indicated that as long as she remained in a structured environment, she was shielded from these stressors and could do quite well.  However, the treatment team cautioned that her risk of suicide would markedly increase as soon as she was re-introduced to these environmental stressors. Therefore, admittance to PHP level of care was urgently needed to prevent serious deterioration of the patients health upon discharge from acute level of care. While participation in a PHP program was a necessary component of the patients post-acute treatment, based upon the psychiatric exam, the patient was sufficiently stable to be discharged from her current program to another program at that time. The patient was noted to be calm and cooperative and reported that she was feeling better. She was also fully compliant with her medications and denied any side effects.  All told, the PHP services were urgently needed services.  Final Result: The reviewer determined that the patient was not experiencing a psychiatric emergency medical condition. However, the PHP services the patient received were urgently needed services. Therefore, the Health Plans denial should be partially overturned.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a computed tomography (CT) angiogram for evaluation of his medical condition. Findings: Two physician reviewers found that the results of a stress echocardiogram was essentially negative for ischemia.  In this circumstance, the post-test likelihood of significant coronary ischemia is very low such that additional testing is not standard accepted practice in the medical community in the absence of documented ongoing symptoms.  Moreover, if an assessment of coronary anatomy is thought to be medically indicated, then conventional coronary angiography is preferred due to its improved accuracy related to coronary CT angiography and the ability to intervene with coronary revascularization during the same procedure if clinically indicated.  Therefore, CT angiogram was not likely to have been superior over other modalities.  Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing.  All three reviewers are experts in the treatments 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 cervical nerve ablation for treatment of her neck pain. Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Radiofrequency ablation is supported in the peer-reviewed literature in this clinical setting. In this case, the patient has had failure of several modalities of treatments. The patient presents with chronic persistent pain with findings of significant facet arthritis.  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 anesthesiology with sub-specialty certification in pain 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Afirma gene expression classifier testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that per the guidelines For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat [fine needle aspiration] FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, submission of the specimen to Afirma gene expression classifier was appropriate to further determine whether surgery was necessary. Without Afirma gene testing surgery would have to be recommended to clarify. This patients result was benign. A benign result most likely prevented unnecessary surgery in this patient and avoided immediate risks of surgery. The rate of unnecessary surgeries has decreased with the use of molecular testing. In this case the decision to refer the biopsy specimen to Afirma testing was appropriate for the best care of this patient and was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and 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 oncology and is actively practicing.  Two reviewers are board certified in endocrinology and metabolism 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.