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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Dexilant 60 mg, two times per day for treatment of the enrollees gastroesophageal reflux disease.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication dosage.  Dexilant, unlike other proton pump inhibitors, is released in an extended fashion.  This delivery system results in an extended plasma concentration and a higher mean 24-hour intragastric pH than other proton pump inhibitors.  The use of Dexilant 60 mg, twice daily is associated with severe adverse effects including hypertension.  Dexilant 60 mg, once daily is supported by current medical literature, but Dexilant 60 mg, twice daily is not.  In patients with scleroderma, who are at higher risk for reflux, twice daily proton pump inhibitor is supported by literature.  However, if twice-daily proton pumps inhibitor is needed, other proton pump inhibitors can be given twice daily, but Dexilant twice daily is not supported.  For these reasons, Dexilant 60 mg, two times per day is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication dosage is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Enbrel for treatment of the enrollees plaque psoriasis. Findings:  The physician reviewer found that Given the location of plaque psoriasis on the scalp, ultraviolet light therapy is not feasible. In addition, the use of acitretin and methotrexate in a female of child-bearing potential is not recommended. The use of cyclosporine may be used for an acute flare of psoriasis, but given the long-term risks of the medication on renal function, this is not an adequate long-term treatment plan. Moreover, the use of anti-tumor necrosis factor (TNF) agents such as Enbrel are considered first-line therapy for psoriasis when systemic treatment is necessary. In this clinical setting, Enbrel for the treatment of scalp psoriasis is medically reasonable and appropriate. Accordingly, the request for Enbrel has been established as 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: Am enrollee has requested reimbursement for real-time remote heart monitor (CardioNet monitor).Findings:  Two physician reviewers found that there is a lack of support for the device at issue in this clinical setting.  In this circumstance, if evaluation for dysrhythmias is thought to be indicated, then Holter monitoring for frequent symptoms or off-line self-activated event monitoring for less frequent symptoms should be sufficient in recording cardiac rhythm during palpitations.  In addition, off-line auto-triggered event recorders should be effective in identifying asymptomatic paroxysmal dysrhythmias.  There is no documentation to indicate the patient is not able to effectively manage these types of devices or that these devices have already been tried and failed.  Current expert consensus guidelines endorsed by several national organizations also consider Holter monitoring and/or patient-activated or auto-triggered event recorders appropriate initial tests and standard of care for evaluation of dysrhythmias.  The medical evidence does not support continuous real-time monitoring by telemetry services in this case, since off-line analysis of a patient-activated or auto-triggered event recorder should be sufficient in the identification of dysrhythmias without jeopardizing patient safety.  Immediate recognition and reporting of dysrhythmias through a call center provided by real-time mobile telemetry services was not indicated, and has not been shown to improve health outcome compared to standard monitoring techniques. Final Result: Two reviewers determined that the device at issue was 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. 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: An enrollee has requested reimbursement and prospective authorization and coverage for acupuncture treatments for treatment of the enrollees fatigue, insomnia, nausea and vertigo. Findings:  The physician reviewer found that acupuncture has been shown to be effective for the management of pain and fatigue related to illness. Acupuncture has demonstrated benefit across a variety of conditions including chronic pain. Peer-reviewed publications provide support for acupuncture in treating anxiety, sleep disturbances, depression and chronic pain. Acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment and at short-term follow-up. The medical records document that this patient has been treated with acupuncture with reported good response and functional gain. All told, the acupuncture treatments were and are medically necessary for treatment of this patients medical condition. 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 neurology 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 reimbursement for autonomic testing.Findings:  Two physician reviewers found that a study notes autonomic testing may be considered in the evaluation of patients with polyneuropathy to document autonomic nervous system dysfunction (Level B). Such testing should be considered especially for the evaluation of suspected autonomic neuropathy (Level B) and distal small fiber sensory polyneuropathy (SFSN) (Level C). A battery of validated tests is recommended to achieve the highest diagnostic accuracy (Level B). Nerve biopsy is generally accepted as useful in the evaluation of certain neuropathies as in patients with suspected amyloid neuropathy, mononeuropathy multiplex due to vasculitis, or with atypical forms of chronic inflammatory demyelinating polyneuropathy (CIDP).  In this patients case, the available medical records provided for review do not indicate any focal neurologic disturbance in regards to motor, sensory, reflex, coordination, gait or cranial nerve or cognitive function.  The available medical records do not report, by history, the presence of any issue of labile blood pressure, orthostatic hypotension, or passing out episodes. There is no indication of neuropathic pain being reported in terms of having hypersensitivity allodynia.  Autonomic nervous system testing is useful for evaluation of autonomic nervous system when there are autonomic nervous system related symptoms. The available medical records provided for review does not support the presence of any subjective symptoms consistent with autonomic nervous system abnormality or indicate any objective findings on physical examination and support of autonomic nervous system dysfunction.  Final Result: Two reviewers determined that the services at issue are 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the stereotactic body radiotherapy (SBRT) performed for treatment of the enrollees prostate cancer. Findings:  Two physician reviewers found that there is a lack of long-term studies supporting the use of SBRT for the treatment of prostate cancer. The literature review concluded that Studies of SBRT provide encouraging results of biochemical control and late toxicity. However, they are limited by a number of factors, including short follow-up, exclusion of intermediate- and high-risk patients, and relatively small number of patients treated. Currently, SBRT regimens should only be used in the context of clinical trials. Moreover, SBRT is not well-established in the literature for high risk disease. Thus, the SBRT performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the services at issue were 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 radiation oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested comprehensive pain rehabilitation for treatment of the enrollee, who has a history of post-concussion syndrome with headaches, sleep disorder, pain disorder with psychological factors and somatic symptom disorder.  Findings: The physician reviewer found that a review of current medical literature support the use of interdisciplinary approaches to pain management in the pediatric population.  The interdisciplinary model of pain management is said to be more effective than isolated approaches to pain management. Research has also shown that more intensive programs tend to have a greater degree of clinical efficacy, in the form of short and long term improvement, than less intensive interdisciplinary treatment.  This has been demonstrated in comparative studies a few colleagues.  In this case, the patient is noted to have a longstanding history of chronic pain, primarily in the form of headaches which have been reported as refractory to most outpatient forms of therapy. The requested interdisciplinary pain program is through an out of network provider but the records indicate that the Health Plan has offered an in network interdisciplinary program. The literature does not show that provision of services from one specific provider group is more effective than what is offered by another. While there is a potential role for intensive pain management program for the treatment of this patient, the submitted documentation does not support that the requested services are medically indicated over the other.  Moreover, the records do not appear to show that the current interdisciplinary services offered by the Health Plan have been fully exhausted, at this time.  Therefore, based on the information stated above, the requested comprehensive pain rehabilitation program to include 15-day outpatient program is not medically necessary for the treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested sofosbuvir/velpatasvir (Epclusa 400-100 mg) for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  Per the guidelines, patients with cirrhosis are high priority for treatment.  Per the guidelines, Epclusa for 24 weeks is recommended as first-line therapy for ribavirin-ineligible genotype 3 patients with decompensated cirrhosis.  This patient is ribavirin-ineligible due to anemia.  For these reasons, sofosbuvir/velpatasvir (Epclusa 400-100 mg) for 24 weeks is medically indicated 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested circumcision for treatment of the enrollees uncircumcised penis.  Findings: The physician reviewer found that children with normal hygiene and no history of infection or inflammation of foreskin do not have a medical necessity for circumcision. Additionally, there is a lack of medical literature or experience that links any changes in self-esteem from differences in appearance between siblings. Finally, elective circumcision can be performed under local anesthesia when children are older, generally, between 8 and 10 years old, foregoing the general anesthetic required in a patient. Accordingly, the requested circumcision is not supported as medically necessary for treatment of this 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 urology with sub-specialty certification in pediatric 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral screening digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. 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.  In this patients case, her breast tissue was described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, bilateral screening digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the service 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 physician reviewers are board certified in diagnostic radiology 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: An enrollee has requested Harvoni 90/400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1b.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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 (Kowdley, et al; Afdhal, et al). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the 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 methadone for treatment of the enrollees chronic pain. Findings:  The physician reviewer found that based on the medical literature and in consideration of the presented clinical records, methadone is not medically necessary for treatment of the patients medical condition. The medical records show the patient to have chronic non-malignant pain. The current standard of care for chronic pain associated with fibromyalgia is treatment in a multidisciplinary practice that includes physical therapy, massage therapy, behavioral therapy, and steroid injections. For the treatment of back pain, a study states that Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy. Similar findings are reflected in the report by another research study which states that Conservative decisions in the treatment of degenerative disc disease are based on interventions made for patients with chronic [low back pain] LBP. There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP. There are a variety of anticonvulsants and anti-depressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. In addition, short-acting opiates are more likely to cause adverse outcomes. Therefore, the request for methadone 10 mg is not medically necessary for 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.