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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret for eight weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 2b.According to recent guidelines, 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 2b patients should be treated with Mavyret for eight weeks. These recommendations apply regardless of fibrosis stage. A trial showed a 99% cure rate with eight weeks of treatment. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential sub-acute detoxification (HCPCS code H0010), residential treatment center services (HCPCS code H0018) and intensive outpatient services (HCPCS code H0015). Findings:  The physician reviewer found that The American Society of Addiction Medicine (ASAM) criteria is an accepted, national standard for determining the appropriate level of care for adults with substance use problems. With regards to acute intoxication and/or withdrawal potential, the patient had mild withdrawal symptoms at the time of admission. In terms of biomedical conditions and complications, the patient did not have any medical problems which required 24-hour monitoring. With regards to medical/addictive/psychiatric comorbidity, the patient does have a history of anxiety and depression. However, on admission, the patient did not endorse any anxiety or depression. In terms of readiness to change, the patient reported that she was motivated for change and wished to engage in treatment. With regards to relapse, continued use or continued problem potential, she had long periods of time with sobriety. The patient has been able to maintain abstinence with minimal support. In terms of recovery/living environment, the patient struggled with her marriage. Based on the ASAM criteria, the patient could have been treated in a less restrictive environment with outpatient services. She also could have engaged in 12-step programs. The medical evidence does not support the services at issue in this clinical setting. All told, residential sub-acute detoxification (HCPCS code H0010) provided, residential treatment center services (HCPCS code H0018) provided and intensive outpatient services (HCPCS code H0015) provided were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sofosbuvir/velpatasvir . 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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that patients should be treated with Epclusa . guidelines cite data showing reduced survival with delayed treatment. For these reasons, sofosbuvir/velpatasvir are 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A 63-year-old male enrollee has requested reimbursement for skilled nursing facility (SNF) services. The documentation reveals that this patient required skilled nursing services on a daily basis for his stage 4 wound care. The patient continued to require daily wound care that involved application of collagenase and alginate with packing and dressing changes daily which is considered a skilled need. Although the patient did not require skilled therapy on a daily basis to prevent deterioration with mobility or to establish a safe and effective maintenance program, the patient did require the special skills and observation of skilled nursing provided at a SNF level of care. The documentation reveals that the patient required skilled nursing monitoring and daily care of his wound and wound cultures, as well as evaluation of his status and wound for infection. All told, the SNF services provided were medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device). Findings:  The physician reviewers found that TIF is an endoscopic procedure performed under general anesthesia to create a full-thickness serosa-to-serosa plication that is 3 to 5 cm in length and 200 to 300 degrees in circumference. TIF can be performed in patients with typical GERD symptoms without or with low-grade erosive esophagitis, and a small hiatal hernia 2 cm or less. Although TIF is associated with fewer postoperative adverse effects such as gas bloating and dysphagia compared with surgical fundoplication, the durability of TIF has not been demonstrated in randomized, controlled, clinical trials. In addition, this patients records do not include objective documentation of acid reflux with a pH study or combined pH/impedance study. For these reasons, the requested heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the requested heartburn surgery (transoral incisionless fundoplication (TIF) procedure with EsophyX device) is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for magnetic resonance imaging (MRI) of the abdomen and pelvis. Abdominal pain is a common clinical presentation. The American College of Radiology (ACR) Appropriateness Criteria serves as general guidelines for various clinical presentations. The specific imaging study recommended for abdominal pain is based on pain location.  Ultrasonography is recommended to assess right upper quadrant pain, and computed tomography (CT) is recommended for right and left lower quadrant pain. In the setting of acute pain, MRI is generally not thought of as a first-line or even second-line approach. There are specific clinical presentations where MRI is indicated, such as patients who are pregnant or patients in whom a CT scan is indeterminate. However, for the most part, MRI is not as optimal as ultrasound and CT scanning. The ACR has also established criteria for the evaluation of vaginal bleeding. Based on the criteria, MRI was not indicated for the evaluation of this patients vaginal bleeding. MRI of the female pelvis is generally reserved for cases when the ultrasound findings are not definitive. On occasion, MRI will better define fibroids and will help confirm the diagnosis of adenomyosis. But for the most part, ultrasonography is sufficient to make these diagnoses. In sum, the medical evidence does not support MRI in this clinical setting. Considering the history of pancreatitis, a CT scan would have been appropriate.  Additionally, in the setting of simple vaginal bleeding, an MRI study is generally not performed. Thus, MRI of the abdomen and pelvis was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for positron emission tomography (PET) scan. Findings: The physician reviewer found that the medical literature has demonstrated a reduced rate of referral for diagnostic coronary imaging following PET as compared to nuclear stress testing with single photon emission computed tomography (SPECT). Some studies have shown a decrease in the use of downstream angiography and revascularization when utilizing PET compared to a SPECT matched group. In the case of this patient, evaluation for ischemia was appropriate given the patients symptoms and prior history of multiple coronary interventions. In addition, the low ejection fraction and wall motion abnormalities on echocardiography required a functional study to plan a possible reperfusion strategy. Conventional coronary angiography would not have provided this type of an assessment. In addition, her previous allergic reaction to technetium precluded the use of nuclear imaging with SPECT. Therefore, the PET scan performed was likely to have been more beneficial for evaluation of this patients medical condition than the available standard techniques. Final Result: Two of the three reviewers determined services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for acupuncture services. The submitted documentation supports the medical necessity of the requested services. This patient has a history of insomnia. She has tried melatonin, with limited benefit. The provider has indicated that even if the patients insomnia is related to her menses, hormones are not an appropriate treatment option given her history of breast cancer. In an undated letter, the patient clarified that her insomnia was worsened by her intermittent chronic pain. For chronic pain patients with limited therapeutic options, an acupuncture trial may be medically appropriate. There is sufficient support for the requested services in this clinical setting. All told, the requested acupuncture services are medically necessary for the treatment of this patient.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 oriental 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

An enrollee has requested authorization and coverage of Mavyret for eight weeks. Findings:  The physician reviewer found that According to the 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 1b patients should be treated with Mavyret for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage.  The ENDURANCE-1 trial showed that only eight weeks of treatment is needed. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mayvret is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified 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 enrollees parent has requested authorization and coverage for intravenous immune globulin (IVIG) with Gamunex-C. Findings: The physician reviewer found that this patients records document antibody proven autoimmune encephalitis. The condition is reported to have not responded to IV steroids and non-steroidal anti-inflammatory drugs (NSAIDs). For these reasons, the requested IVIG with Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings: Three physician reviewers found the requested IVIG with Gamunex-C is 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 IVIG with Gamunex-C is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Credentials/Qualifications: Physician reviewers 1, 2 and 3 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: An enrollee has requested reimbursement for residential treatment center services and substance use treatment. Due to the lengthy history of substance use and lack of a sober support network, a residentially-based preliminary introduction to chemical dependency treatment was medically appropriate. However, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting as of 1/27/18. This patient embraced recovery principles and was both active in treatment and motivated in his quest for sobriety. He was not experiencing withdrawal or significant medical or psychiatric symptoms. He was stable on psychotropic medications that were not being adjusted.  He was future oriented, and he had access to safe housing. Although the parent-child dynamic was strained, he had a supportive family. The records on 1/26/18 indicated that the patients mother was available to live with him. This was significant for both supportive and therapeutic purposes, particularly since the patient had prior success with sobriety when residing with his parents. Further, the patient had no prior history of chemical dependency treatment, such as anti-craving medication, 12-step facilitation, contingency management or cognitive behavioral therapy, in the community, outpatient, intensive outpatient or partial hospital settings.  This is significant in this case for two reasons. First, modern psychiatric practice favors treatment in the community, as outcome measures and therapeutic gains are optimized in this environment. Second, there was no evidence to suggest that comprehensive, evidence-based services provided in a less restrictive treatment setting would have been insufficient or inadequate at the time.  Thus, residential treatment center services and substance use treatment provided from 1/23/18 through 1/26/18 were medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 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. Findings:  Three physician reviewers found there is sufficient support for the requested services in this patients case. Botox has been shown to be effective for the management of chronic migraine. Botox has been approved by the U.S. Food and Drug Administration (FDA) for use in prophylactic management in chronic migraine. This patient fits the criteria for chronic migraine. The enrollee has failed accepted preventative therapies, including medications within the antihypertensive and antidepressant classes. Therefore, Botox is likely to be superior over other available treatment options in this clinical setting.Final Result: The reviewers determined that the requested services are 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: Physician reviewers 1, 2 and 3 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the medications Farxiga and Trulicity. The Health Plan has denied this request indicating that the requested medications are not medically necessary for treatment of the enrollees type II diabetes. There is a lack of support in the medical literature for the medical necessity of the requested medications in this clinical setting. As such, the request for Farxiga is not medically necessary because the alternative formulary medication Jardiance is available for treatment of this patient. With regards to the medication Trulicity, the medical necessity for this medication has not been demonstrated in this patients case.  Trulicity is a receptor agonist, which is an incretin, and should not be taken at the same time with another incretin, inhibitor. Trulicity can be an effective next step therapy for this patient because of its effect on weight and glucose levels. Trulicity would be medically indicated. However, based on the documentation as well as the literature, Trulicity is not medically necessary for treatment of this patients medical condition at this time. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in endocrinology and metabolism. 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. Findings:  The physician reviewer found that