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

Nature of Statutory Criteria/Case Summary: An enrollee has requested requested authorization and coverage for Epclusa for 12 weeks for treatment of the enrollee's 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 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, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. For these reasons, Epclusa for 12 weeks is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Botox for treatment of the enrollees pelvic floor disorders.Findings: The physician reviewer found that the requested service is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The treatment available for medication refractory overactive bladder disorders includes Botox injections, nerve stimulations therapy or augmentation cytoplasty. Of the options available, Botox injections are the least invasive and can be performed as an outpatient with immediate relief of symptoms. In this clinical setting, Botox injections are a reasonable treatment option for this patient and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested service 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: All three physician reviewers are board certified in urology and are actively practicing. The reviewer 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 interstitial brachytherapy treatments for treatment of the enrollees ductal carcinoma in situ (DCIS). Findings:  The physician reviewer found that APBI describes delivering adjuvant radiation to part of the breast after breast conserving surgery for early stage breast cancer. Delivery options include external beam intensity modulated radiation therapy (IMRT), brachytherapy catheters, electronic brachytherapy, intraoperative radiation therapy (IORT) and the MammoSite balloon. In general, the radioactive sources are delivered via multiple channels, each with multiple dwell positions. In this case, catheters would be placed, and afterloaded high dose rate sources would be used to deliver radiation. A recent study investigated APBI among 53 women with DCIS. The authors reported excellent survival and low breast tumor recurrence. In addition, others found pooled analysis reporting ipsilateral breast tumor recurrence rates of 2.6% at five years with no regional recurrences following treatment with APBI. Thus, the use of APBI for patients with DCIS, while not supported by level 1 evidence, is considered a viable treatment option in evidence based consensus statements from the American Society for Radiation Oncology (ASTRO) and American Brachytherapy Society (ABS). This patient is being considered for a clinical trial, which is a Phase II study. Given these findings, the requested interstitial brachytherapy treatments was medically necessary for treatment of this patients DCIS. 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 radiation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for custom foot orthotics for treatment of the enrollees foot pain. Findings: The physician reviewer has found that the submitted documentation fails to demonstrate the medical necessity of the equipment at issue.  According to standard of care guidelines, orthotics are indicated for patients with diabetes and risk factors associated with their feet.  Furthermore, some bracing is considered medically necessary if they are on a shoe that is an integral part of a medically necessary leg brace. The criteria for standard care are not supported in the documentation provided.  Moreover, the records do not indicate that the foot orthotics would alleviate this patients condition or that other standard treatment options had been exhausted prior to obtaining the custom orthotics. For these reasons, the equipment at issue was not medically necessary for treatment of this patient. Final Result: The reviewer determined that the equipment at issue was 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 podiatry 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 for the continued psychiatric residential treatment center (RTC) services rendered for treatment of the enrollees behavioral health issues.Findings: The physician reviewer found that the patients medical records indicate the patient had been in prior treatment modalities of different levels of care. Progress notes directly prior to the patients RTC admission indicate that the treatment team believed the patient was in need of RTC level of care due to her risk of self-harm and suicide. The patient has had numerous relational problems with her family and was given a parent-child relational diagnosis. During the initial portion of the patients stay she expressed somatic complaints and complained about taking psychotropic medication. She did not have any self-harm behaviors or aggression towards any other peers. However, she was minimally invested in her treatment and further outpatient treatment would not likely have engaged her appropriately. As her stay progressed, she became more invested in her treatment and was noted to be insightful into her own problems as well as the problems of her peers. Thus, the initial portion of her stay was medically necessary due to her numerous treatment failures at lower levels of care and the recommendation from the inpatient treatment team. However, after her initial stabilization period, she could have then been treated in a less restrictive setting due to the fact that she was not engaging in any dangerous behaviors, was cooperative in treatment, and had gained insight into the benefit of continued need for treatment. Moreover, the progress notes do not reflect that intensive family therapy was occurring while the patient was in the RTC, which was a source of the patients functional problems. Intensive family therapy could have occurred in a less restrictive treatment setting. In addition, the patient could have received DBT in a less restrictive setting (Mehlum, et al). For these reasons, the continued psychiatric RTC services rendered were medically necessary for treatment of this patients behavioral health condition, and the services were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a total abdominal hysterectomy for chronic pain, endometriosis, pelvic adhesions, and polycystic ovarian syndrome. Findings:  The physician reviewer found that The patient has had well documented chronic pelvic pain. There has been a thorough attempt at conservative management to avoid hysterectomy in this patient.  She has tried oral contraceptive pills, Lupron, pain medication, anxiolytic medications and has undergone two laparoscopies.  Laparoscopies have demonstrated that the patient has adhesive disease that mostly involves the uterus and adnexa.  While there is no guarantee that the patient will be cured of her pelvic pain with a total hysterectomy and bilateral salpingectomy, there is good evidence that the majority of women with chronic pelvic pain have significant improvement with surgery. In addition, the patient had the suggestion of liver hemangiomas on her CT scan, which makes her a poor candidate for long term therapy with oral contraceptive pills. In sum, she has failed conservative management for treatment of her pelvic pain. Therefore, the requested total abdominal hysterectomy is medically necessary for treatment of this patient.  Final Result: The reviewer determined that the requested procedure 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 obstetrics and gynecology 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 an electric scooter for treatment of her osteoarthritis of the right knee. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records indicate that the patient has a decreased subjective tolerance to ambulation, but is otherwise an independent community ambulator without an assistive device. The patient does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices, such as the walker which was proposed in rehabilitation medicine clinic.  Physical activity and exercise, moreover, are generally appropriate and recommended in the setting of obesity and for general musculoskeletal health.  A power mobility device such as an electric scooter is not medically appropriate for this patient.  All told, the requested electric scooter is not medically necessary for the treatment of this patient.Final Result: The reviewer determined that the requested equipment 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for the CHG exome sequence analysis for evaluation of the enrollees sensorimotor neuropathy.Findings: All three physician reviewers found that while genetic testing is not indicated for all patients with neuropathies, it is reasonable for well selected patients. In this case, the patient has a progressive neuropathy of unknown etiology. The patient has some clinical features that may suggest a non-hereditary etiology including an elevated CSF protein and gammopathy. It is therefore important to determine the specific etiology of the neuropathy as a hereditary neuropathy is managed differently from an inflammatory neuropathy or neuropathy due to a gammopathy. Genetic testing is an appropriate method to determine if the patient has a hereditary etiology. Therefore, the request for CHG exome sequence analysis is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: All three physician 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: All three physician reviewers are board certified in neurology 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: The parent of an enrollee requested reimbursement and prospective authorization and coverage for intensive outpatient therapy (IOP) for treatment of her behavioral health condition.  Findings: The reviewer found there is sufficient support in the documentation for the services at issue in this clinical setting. To objectively determine the appropriate level of care for the patient, this case was examined using the Child and Adolescent Level of Care Utilization System (CALOCUS). This is an accepted, national standard for determining the appropriate level of care for children and adolescents. According to CALOCUS criteria, her risk of harm is considered significant with a score of 3.  Recent gains in her functionality have been achieved while participating in structured settings. The patient has trouble with social interactions due to her emotional dysregulation. Her functional status is moderate with a score of 3. The patient has a comorbidity of bipolar disorder and substance abuse.  Accordingly, her comorbidity score is a 3 with significant comorbidity. As to this patients environmental stress, it is scored as mildly stressful with a score of 2. The patients parents are supportive. There is some stress and discomfort due to expectations for school and home performance by the patient. As noted in the documentation, this patients parents are supportive and so her environmental support is scored a 2. The records indicate that the patient has a limited ability to deal with stressors. She copes with stressors by cutting and still struggles with emotional dysregulation.  Recovery has been maintained for moderate periods of time. As to her resiliency and treatment, her score is a 3 with equivocal resiliency and response to treatment. It appears that the patient is cooperative and compliant with treatment recommendations from her medical providers. She is able to develop a positive relationship with care providers. As such, her acceptance and engagement would be constructive with a score of 2. This patient according to the CALOCUS system has a composite score of 18. Therefore, the patient has met and does meet criteria for IOP services.  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 with expertise 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 authorization and coverage for WalkAide for treatment of the enrollee, who has history of right foot drop, functional gait disorder, and pressure ulcer of the right foot. Findings: Three physician reviewers found that the requested equipment is documented extensively in the medical literature as beneficial for central nervous system neurological injuries but not for peripheral nervous system pathology. While the provider stated that WalkAide will provide dorsiflexion assistance in this patients case, the current studies are lacking.  There is a lack of peer reviewed literature to support a rationale or mechanism by which the requested treatment would be effective or operational for a peripheral nervous system lesion as described in this patients case.  In sum, WalkAide is not likely to be more beneficial than the standard treatment options for this patient.Final Result: The three reviewers determined that the requested equipment 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: All three physician reviewers are board certified in physical medicine and rehabilitation and are actively practicing. The reviewer 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 doxycycline for treatment of the enrollees rosacea and perioral dermatitis. Findings: The physician reviewer found that rosacea is a common chronic inflammatory disorder of the facial skin characterized by periods of exacerbation, remission and possible progression. The major subtypes include erythematous telangiectatic rosacea and papulopustular rosacea. Individual subtypes are likely a result of different pathogenic factors, thus will respond best to different therapeutic regimens. Rosacea is a polymorphic disease precipitated by many causes including genetic, vascular, immune-mediated, emotional, environmental, and infectious factors. The non-pharmacologic approach to therapy is adequate skin care, trigger avoidance and photo protection. In addition, there are several topical, herbal, systemic and light based therapies available. Current U.S. Food and Drug Administration (FDA) approved treatments include topical sodium sulfacetamide, metronidazole, and azelaic acid. Combination of azelaic acid or topical metronidazole with anti-inflammatory doxycycline appears to have a synergistic effect. Additional topical therapies including benzoyl peroxide, clindamycin, retinoids, topical steroids, calcineurin inhibitors, and permethrin have not been approved for the treatment of rosacea and play variable roles in the management of this condition. Di Nardo and colleagues reported that in a recent clinical trial, 170 adults with papulopustular rosacea were treated for 12 weeks with doxycycline 40 mg compared with cathelicidin and protease activity in stratum corneum samples obtained by tape strip and in skin biopsy specimens. The authors reported that treatment with doxycycline significantly reduced inflammatory lesions and improved investigator global assessment scores compared with placebo. Given this support, the requested doxycycline DR 40 mg is medically necessary for treatment of this patients rosacea. 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 dermatology 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 her treatment of 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 recommendation applies to all patients, regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as a first-line regimen for non-cirrhotic, treatment-naive, genotype 3 patients. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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.