Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested air ambulance services provided on an emergent basis.  Findings:  The physician reviewer found that at issue in this case is whether a prudent layperson would reasonably believe that air ambulance transportation services were required. In this case, the patient sustained a ground level fall resulting in a comminuted fracture. Paramedics arrived on scene and informed the patient that she required air ambulance transport to a medical facility. Per the submitted incident report, the paramedics requested that air ambulance transport be dispatched to the scene due to the severity of the patients comminuted fracture. A prudent layperson would not have refused air transport in this situation but rather would follow the advice and recommendation of the first responders. All told, based on the documentation provided for review, a prudent layperson in this situation would have reasonably believed that air ambulance transportation services were required. Final Result: The reviewer determined that the patient met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in emergency 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 self-injectable testosterone injection (cypionate) for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Low testosterone can lead to complications including reduced libido/erectile dysfunction, reduced muscle mass and strength, increased adiposity, osteoporosis/low bone mass, depressed mood and fatigue.  For these reasons, many providers treat patients with hypogonadism when their testosterone level is less than 350 ng/dL.  The general target level for testosterone ranges from 350 to 750 ng/dL, which is roughly the range for healthy, androgen-sufficient adult men. Testosterone levels should be monitored three to six months after initiation of treatment in order to assure that the patients testosterone level is optimal and the dose of testosterone replacement therapy should be adjusted accordingly.  This patient has clinical and biochemical evidence of hypogonadism and is likely to benefit from testosterone replacement therapy.  Therefore, self-injectable testosterone injection (cypionate) 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 endocrinology, diabetes and metabolism 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 trigger point injections for treatment of his multiple joint pains.  Findings:  The physician reviewer found that according to Simons and Travell, trigger points are discrete, focal, hyper-irritable spots located in a taut band of skeletal muscle. In this patient, there is inadequate documentation that trigger points were identified upon examination. Trigger points are painful on compression and can produce referred pain, referred tenderness, motor dysfunction, and autonomic phenomena (Simons). Simons and Travell outline the following method for providers to identify a trigger point as opposed to another diagnosis: conducting a focused medical history; identifying a meticulous history of the onset of pain; detailing the pain pattern; demonstrating the restricted range of motion; and placing a finger unerringly on the exquisitely tender trigger point. This method of documentation has not been clearly documented in the submitted records. Furthermore, based on the documentation provided, it does not appear other less invasive treatment modalities have been attempted. As trigger point injections utilize an injectable solution they pose increased risk to this patient who presents with elevated transaminase and lactic acid dehydrogenase (Chan, et al). For these reasons, the requested trigger point injections 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 anesthesiology with sub-specialty certification in pain management 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 Ribasphere Ribapak for treatment of his hepatitis C virus (HCV). 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. AASLD/IDSA provides the following justification for the above treatment recommendation: Sofosbuvir 400 mg daily was combined with weight-based ribavirin (RBV), 1000 mg to 1200 mg, to treat HCV genotype 2 treatment-naive patients across 3 clinical trials: FISSION, POSITRON, and VALENCE. The FISSION study randomized patients to daily pegylated interferon and ribavirin (800 mg) for 24 weeks or sofosbuvir plus daily weight-based ribavirin 1000 mg to 1200 mg. The sustained virological response (SVR) was higher (94%) in patients who received sofosbuvir plus ribavirin compared with those who received pegylated interferon and ribavirin (78%). Across all 3 trials, 201 of 214 (94%) patients with HCV genotype 2 achieved SVR with sofosbuvir plus ribavirin. This patients records do not support advanced fibrosis; however, the medical necessity of HCV treatment, as per AASLD/IDSA recommendations, exists regardless of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months); this patients life expectancy exceeds this limit. For these reasons, the requested Sovaldi and Ribasphere Ribapak is medically necessary for the treatment of this patients hepatitis C virus.  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-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 implantation of intrastromal corneal ring segments (INTACS) for treatment of his medical condition. INTACS offers a safe and effective option for treatment of keratoconus. It avoids the need for penetrating keratoplasty in which the entire thickness of the cornea is removed and replaced with corneal tissue. Penetrating keratoplasty involves a long healing process and may be subject to graft rejection and other issues. As such, the INTACS procedure was a more appropriate option for treatment of the patients keratoconus. All told, the submitted documentation demonstrates the medical necessity of the INTACS surgery.Final Result: The reviewer determined that the procedure at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The physician reviewer is board certified in ophthalmology 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 Suboxone for treatment of his behavioral health condition.  Findings:  The physician reviewer found that buprenorphine is approved by the U.S. Food and Drug Administration (FDA) for the treatment of opioid dependence.  The patient was prescribed a buprenorphine combination medication that was medically necessary and consistent with accepted medical practice. The dispute central to this case is that the Health Plans non-preferred preparation of the clinically indicated medication was prescribed (film as opposed to sublingual tablet).  There was no evidence in the medical record to suggest that the Health Plans preferred equivalent medication, would have been diverted, poorly tolerated, inefficacious or inadequate at the time.  Thus, although the pharmacologic intervention was indicated, the particular medication was not medically necessary. Final Result: The reviewer determined that the medication 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 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 a prescription of Lantus Solostar insulin pen for the treatment of his diabetes. Findings:  The physician reviewer found that insulin therapy is often essential for effective management of type 2 diabetes, as well as type 1 diabetes, and optimization of insulin therapy reduces the progression of diabetes and the development of diabetes-related complications (Kumar, et al).  Insulin pens have become increasingly available and have been associated with improved ease of use, user confidence, treatment satisfaction, and quality of life compared with vials and syringes. In this case, the Lantus Solostar insulin pen is indicated for this patient given that the pen is easier to use and may enable more precise dosing. In sum, the request for Lantus Solostar insulin pen is medically necessary for treatment of the patients medical condition.  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 physician reviewer is board certified in endocrinology and metabolism 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 substance use residential treatment services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation failed to support the medical necessity of the treatment intervention, as the record failed to demonstrate that less restrictive interventions targeting her substance use during the episode of illness had either been unsuccessful or would have more than likely been inappropriate.  There was no evidence of acute medical or psychiatric comorbidity.  Although her cravings were increasing, the patient was motivated to stay sober and able to identify a precipitant to her urge to drink.  She was neither engaged in specialty treatment services nor was prescribed an anti-craving medication.  In sum, there was no evidence to suggest that comprehensive specialty services provided at a lower level of care would have been unreasonable or consistent with inadequate care.  Thus, substance use residential treatment was not medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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 radiofrequency neurotomy (ablation) for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. The medical literature is clear that a diagnostic medial branch block is supposed to be performed prior to radiofrequency ablation; specifically, using a pain diary to verify when the local anesthetic wore off. In the submitted documentation, the provider does not document a pain diary for a medial branch block prior to the previous radiofrequency ablation. Moreover, based on the notes from the patients prior radiofrequency ablation procedure, it appears the patient would obtain the same relief from a steroid injection alone without being subjected to increased risk from radiofrequency ablation. The records also do not indicate a prior failure from facet injections nor is there any documentation as to having the test redone to ensure the correct sites are still being treated. The submitted medical records do not mention an increased functional benefit from baseline and no decrease in perceived pain from baseline with the patients previous radiofrequency ablation procedure. Instead the records indicate that the previous radiofrequency ablation did not help her pain in her forearms and hands.  Furthermore, the documentation demonstrates that after the first radiofrequency ablation, the patients use of opioid medications has increased from very minimal to much higher doses. Moreover, the patients surgeon had recommended against a repeat of the procedure and instead discussed other treatment options that have not yet been attempted by this patient. Therefore for all these reasons, the requested radiofrequency neurotomy (ablation) is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested procedure 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 management 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 medical condition. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted in the literature, this technology has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.  Final Result: Three 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 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: 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. 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. The guidelines recommend that treatment-naive genotype 1a 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.  For these reasons, the requested treatment with Harvoni 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides significant advantages due to its tomographic nature.  This modality allows providers to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of greater benefit to this patient than had the examination been done with two-dimensional technique alone.  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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cialis for treatment of his medical condition. Findings: The physician reviewer found that Cialis is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Cialis is U.S. Food and Drug Administration approved for the indication of erectile dysfunction or symptomatic benign prostatic hyperplasia. Coward and Carson report recent studies show a significant treatment benefit from once-daily, low-dose tadalafil. Given the support for the proposed medication dosage, Cialis is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication dosage 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 urology 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.