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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested eight hours of psychological and academic testing for evaluation of the enrollees behavioral health condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Psychological testing in children is performed to address a specific clinical question.  In this case, the stated purpose of the testing is to differentiate anxiety from depression and attention deficit/hyperactivity disorder.  These conditions are usually diagnosed by history and clinical interview rather than psychological testing. Although the parent states that the patient has had years of failed treatment, records documenting previous psychiatric evaluation as well as the patients treatment history have not been provided.  Further, with regard to academic testing, evaluation of students who are not performing well academically in order to determine if the reason is intellectual, cognitive, emotional, or a combination of these is considered a school-based service. Self-report as well as parent and teacher report forms and scales are also readily available to assist in this process.  All told, the requested eight hours of psychological and academic testing is not medically necessary for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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: 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 virus.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. Additionally, patients with cirrhosis are considered highest priority for treatment.  In treatment-naive genotype 1 patients (cirrhotic or not cirrhotic), therapy is recommended with Harvoni for 12 weeks, as a Class I, Level A recommendation. 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. Based on evidence efficacy in the published literature, and clinical guidelines, Harvoni should be considered medically necessary for 12 weeks in this patients case. Final Result: Three reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: 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:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Initiation of treatment with early-stage disease may avoid untoward complications from advanced disease, including liver failure and extrahepatic manifestations of hepatitis C.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: Two reviewers 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 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 a right brace for treatment of her anterior cruciate ligament (ACL) injury. Findings:  The physician reviewer found that the standard of care in the setting of therapy for anterior cruciate ligament (ACL) injuries is physiotherapy with a focus on recovery of strength, range of motion and agility. When relevant, this is often followed by gradual return to sports activities starting with basic agility and sports-specific drills, then part-time and full-time competition. If swelling develops or there is loss of range of motion, activities are reduced until the swelling subsides and range of motion restored. A neoprene sleeve can be used as an option for additional support. However, a functional ACL brace has not been proven in the medical literature to be an effective intervention for this condition. Authors performed a systematic review of the extant level one evidence (consisting of 12 randomized controlled trials) of bracing in the setting of postoperative recovery. The authors reported they found no evidence that pain, range of motion, graft stability, or protection from subsequent injury were affected by brace use, supporting their hypothesis that the use of postoperative ACL braces could not be rationalized by evidence of improved outcome including measurements of pain, range of motion, graft stability, or protection from injury. A large scale randomized, controlled clinical trial, concluded that, A functional knee brace does not result in superior outcomes compared with a neoprene sleeve after ACL reconstruction. Current evidence does not support the recommendation of using an ACL functional knee brace after ACL reconstruction. In addition, the literature concluded that the use of a postoperative knee brace does not affect the clinical outcome after ACL reconstruction. In sum, there is insufficient evidence in the medical literature that would support the medical necessity of the device at issue for this patient. Moreover, the documentation submitted for review fails to demonstrate the patient has knee instability. Based on the medical literature and clinical documentation provided, the right brace was not medically necessary for treatment of the 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 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 requested Consentyx for treatment of his psoriasis. Findings:  The physician reviewer found that psoriasis is a chronic skin disease with new emerging understanding of the contributing immunologic pathways. Consequently, new targeted therapies have been developed to gain better control over this disease. This patient has failed therapy. He is requesting coverage for Cosentyx. The letter of appeal indicates a contraindication to methotrexate, cyclosporine and acitretin. However, there is a lack of laboratory data provided to demonstrate a contraindication to methotrexate, such as a transaminitis or evidence of active hepatitis infection. Further, there is no confirmation of treatment failure or adverse reaction to these treatments. Since the patient has not demonstrated a failure to respond or related adverse effects from an oral systemic agent for treatment of psoriasis, the requested Consentyx is not supported as medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 12 weeks for treatment of his chronic hepatitis C virus genotype 3.  Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated without regard for fibrosis staging. Patients with cirrhosis are considered the highest priority for treatment and patients with genotype 3 with cirrhosis who have failed prior therapy with peginterferon and ribavirin are recommended to be treated with Sovaldi, peginterferon and ribavirin for 12 weeks.  All told, the requested Sovaldi for 12 weeks is medically necessary for treatment of this patients hepatitis C virus.  Final Result:  Three reviewers 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested Zomig Spray for medical treatment of her refractory migraine with aura.  Findings:  The physician reviewer found that Zomig has been demonstrated to be effective for the treatment of migraine. Zomig Spray has onset of action as soon as 10 minutes, and is parenteral, so is effective when patients have nausea and vomiting and are unable to take an oral medication. As this patient has severe migraines with nausea and vomiting, she requires a parenteral route of administration for her migraine medication. This patient has tried numerous triptans with inadequate response, but has reported satisfactory results with Zomig Spray. Thus, the requested Zomig Spray is medically necessary for treatment of this patients migraines.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 neurology 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 requested intensive outpatient program (IOP) services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The patients problems appear to be chronic in nature including social difficulties. These issues are not an appropriate focus for IOP treatment but better handled on an outpatient basis. It does further appear that the patient did respond to the treatment that was provided, which included access to various groups and medication management. The requested services are not medically necessary for treatment 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 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 chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/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 patients. Patients who are cured of their hepatitis C infection experience numerous health benefits, including a decrease in liver inflammation as reflected by improved aminotransferase levels and a reduction in the rate of progression of liver fibrosis. Per the U.S. Food and Drug Administration (FDA) recommendation, this patient meets the criteria for treatment with Harvoni for 12 weeks to prevent further progression of cirrhosis. Consistent with this support, the requested treatment with Harvoni for 12 weeks is medically necessary for treatment of this patients hepatitis C viral infection. Final Result: Two reviewers 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 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 Subsys for treatment of her chronic pain syndrome.  The physician reviewer found that according to the current peer-reviewed medical literature, fentanyl sublingual spray (Subsys) is a novel formulation of fentanyl for sublingual delivery and was designed to enhance the rate in extended absorption of fentanyl for management of breakthrough cancer pain. According to the clinical records submitted for review, the patient utilizes this medication due to a history of side effects with previous medications, and difficulty swallowing and digesting oral medications and is in constant, severe pain. However, the clinical records submitted for review provide no evidence or indication that the patient is currently experiencing breakthrough cancer pain or that the patient has been diagnosed with any form of cancer. Further, the clinical records submitted for review lack exceptional factors which would warrant the use of this medication. Based on the documentation submitted and in consideration of the diagnosis, the care provided, and the clinical condition, as well as the medical history of the patient, the requested Subsys medication is not medically necessary. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her right breast pain.  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long term studies proving increased survival rates when digital breast tomosynthesis has been added to the usual films of screening mammography, the technique has gained wide support among providers due to an associated decrease in callbacks and increased detection of small cancers. Thus, the addition of breast tomosynthesis was likely of more beneficial to the patient than digital mammography without tomosynthesis.  Final Result: Three reviewers determined that the diagnostic procedure 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 diagnostic radiology 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:  The parent of an enrollee has requested an immune cell function assay for evaluation of the enrollees behavioral regression, strep pneumonia, cough, and autoimmune disease, not elsewhere classified. Three physician reviewers found that according to the medical literature, certain entities such as PANS and pediatric neuropsychiatric disorders after streptococcus infection (PANDAS) have been described as autoimmune disorders. However, the evidence that entities such as PANDAS are autoimmune has not been definitively established. PANS is a symptom complex whereby draft criteria have been established by experts to describe the entity. Based upon the available evidence-based literature, PANS is an area of ongoing research without defined standards of care for laboratory diagnosis or treatment where even the diagnostic criteria are the subject of study. A set of published expert recommendations for the clinical evaluation of pediatric patients with PANS did not include immune cell function assay as part of the published guidelines for immunology work-up for this condition. Based upon the evidence-based literature reviewed, the immune function assay was not likely to be more beneficial for evaluation of this patients medical condition than any available standard testing.  Final Result:  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: One reviewer is board certified in pediatrics and pediatric critical care and is actively practicing. One reviewer is board certified in internal medicine, rheumatology, and allergy and immunology and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in neurodevelopmental behavioral pediatrics and is 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 a power scooter for treatment of the enrollees osteoarthritis. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power scooter. Auger and colleagues performed a literature review of power wheelchair usage and assigned most of the research designs as very low quality. Power mobility can benefit specific patients. However, in the present case there is a lack of evidence supporting the medical necessity for power mobility. In this case, the patient has impairment of functional mobility but is able to ambulate throughout the household to perform self-care activities with use of a cane to assist movement. A wheelchair has been requested for impairment of functional mobility by his provider. However, a detailed physical therapy evaluation showed the patient is a functional household ambulator with a cane and that he does not want to use a walker which would be the next most advanced assistive device to consider after a cane. After a walker, a manual wheelchair, which the patient is able to propel, would be considered. Finally, last in the hierarchy of assistive devices comes a power mobility device. The physical therapy evaluation found the patient does not have a need for a power mobility device within the home and there is a lack of evidence in his medical records that he needs one for the community. Based on the clinical documentation submitted, a power scooter is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment is not medically necessary for evaluation 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 with sub-specialty certification in neuromuscular 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.