Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bronchial thermoplasty for treatment of her severe persistent asthma. Three physician reviewers found that per Torrego and colleagues, bronchial thermoplasty for patients with moderate to severe asthma can provide a modest clinical benefit in quality of life and lower rates of asthma exacerbations. Wahidi and Kraft reported that bronchial thermoplasty is an option for patients with severe asthma who continued to be symptomatic despite maximum medical treatment. However, there is a paucity of randomized controlled trials on patients with severe persistent asthma who experience more than three exacerbations of asthma in one year. This patients records document frequent exacerbations to include at least four to five times per year. Given the lack of data demonstrating superior health outcomes in this patient population, the requested bronchial thermoplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are 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:  One reviewer is board certified in pulmonary diseases with sub-specialty certification in critical care and sleep medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary diseases 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 weekly individual therapy with a psychologist for treatment of his depression and adjustment disorder.   The physician reviewer found that this patients underdeveloped ego-strength is consistent with distorted beliefs about his self, his personal world and his future, which is synonymous with the classic cognitive triad. As such, the patient can be expected to do well with cognitive based therapy. As noted by Sadock and colleagues, there is ample evidence supporting the role of cognitive behavioral therapy (CBT) in patients with depressive disorders. Considering family history, the cyclical maladaptive patterns of behavior and the chronicity and nature of the symptom complex, a typical course of CBT consisting of 12 weekly sessions of individual CBT provided, followed by a diagnostic re-evaluation to assess progress and ongoing treatment needs, is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a clinical chemistry test (cancer risk using panels of genes for evaluation of her right breast cancer.   Two physician reviewers found that in the clinical progress notes, genetic testing for BRCA is mentioned after a cancer genetics consultation. However, there is no genetics consultation report included for review in the case file. A general screen for hereditary breast cancer was ordered but it is not clear that this is appropriate panel since there are genes implicated in Lynch syndrome. Applying the National Comprehensive Cancer Network (NCCN) criteria for testing, the clinical chemistry test (cancer risk using panels of genes) was not likely to have been more beneficial in evaluating this patients medical condition than standard available testing.  Final Result: Two 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 internal medicine with sub-specialty certifications in oncology and hematology and is actively practicing. Two reviewers are board certified in internal medicine with a sub-specialty certification in medical oncology 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:   The parent of an enrollee has requested 16 additional hours of home health shift care for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a complex medical condition that requires close supervision and care.  This care should be provided either through home health care or a skilled family member.  The Health Plan has approved coverage for 40 hours of home health shift care per week, which is medically appropriate.  The records do not document the need for greater than 40 hours of home health shift care.  All told, the requested additional 16 hours of home health shift care is not medically indicated 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 pediatrics 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

An enrollee has requested skilled nursing care at a rehabilitation center for treatment of her acute pulmonary embolism.  Nature of Statutory Criteria/Case Summary:   The physician reviewer found that the requested skilled nursing care at a rehabilitation center was not and is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient has made progress in the skilled nursing facility to the point where she is nearly to the functional level where she was prior hospitalization.  In this clinical setting, additional physical therapy and occupational therapy evaluations are indicated to determine if skilled services are necessary. For the reasons provided, the services at issue were not and are not medically necessary at this time. Final Result: The reviewer determined that the services at issue were not and 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  Xolair for treatment of her severe asthma.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The Health Plan noted that the patients IgE level was over the recommended range for treatment with Xolair.  However, there are studies that show Xolair treatment is beneficial and safe for patients with IgE levels higher than 700 IU/mL.  There is sufficient support for the requested medication in this clinical setting.  This patient has shown significant clinical improvement with the use of Xolair, as her asthma symptoms improved with this medication.  All told, the requested medication Xolair 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 and allergy and immunology 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 anterior lumbar interbody fusion at L4-S1 for treatment of his degenerative disc disease at L4-5 and L5-S1.   The physician reviewer found that overall there is a lack of evidence from controlled trials that spinal fusion alone is effective for treating acute low back pain in the absence of spinal fracture, dislocation or spondylolisthesis with instability. In this case, there is no degenerative spondylolisthesis documented and there is no evidence of instability. In addition, there is no radicular pain below the knee or objective findings of radiculopathy in the lower extremities. Moreover, the imaging studies do not show any nerve root compression. All told, the evidence based guidelines do not support the requested fusion from L4 to S1 as medically necessary for treatment of this patients back pain. Final Result: The reviewer determined that the requested surgery 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 orthopedic surgery 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 transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health condition. The physician reviewer found that TMS is approved by the U.S. Food and Drug Administration (FDA) for the treatment of adult patients with major depressive disorder who have failed to receive satisfactory improvement from one prior antidepressant medication at or above the minimal effective dose and duration in the current episode. The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. The specific age range defining an adult is commonly assumed to be 18 years of age unless otherwise stated. This assumption is by the National Institute of Mental Health which reported, In 2013, there were an estimated 10 million adults aged 18 or older in the U.S. with [serious mental illness] SMI, In this case, the patient presents with chronic affective illness and has pursued standard therapies used to combat depression. TMS is approved for the adult population, and has evidence of utility and safety for patients 18 years of age and older.  Considering the medical records submitted for review, endorsement from the APA and the peer-reviewed literature, TMS represents a safe, appropriate treatment consistent with good medical practice that is reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested therapy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested therapy 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 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 Sovaldi for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The initiation of treatment will help avoid further progression of fibrosis.  All told, Sovaldi 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 neurofeedback for treatment of his traumatic brain injury. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient is status post traumatic brain injury and is requesting neurofeedback for treatment of his perceived cognitive deficits. Neurofeedback is not routinely use by neurologists or physiatrists, and there is a lack of support for the requested services in this clinical setting.  In this case, the patient is requesting this treatment based on his subjective impression he is having cognitive issues.  However, there is a lack of documentation of a problem which would necessitate the requested services.  Formal neuropsychological testing can help determine if the patient is having cognitive issues to determine the need for cognitive rehabilitation done by speech therapy or a neuropsychologist.  All told, the requested neurofeedback treatment is not medically indicated 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 Harvoni for 8 weeks for treatment of her hepatitis C.   Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this patients case.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, 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.  The guidelines recommended urgent initiation of treatment for patients with advanced fibrosis or compensated cirrhosis.  Early initiation of treatment may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, Harvoni for eight 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 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 Flector patch for treatment of her medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Oral nonsteroidal anti-inflammatory medications are contraindicated in patients who have a side effect of gastrointestinal irritation due to increased risk of gastric ulcers and gastric perforation.  In this patients case, there is no documentation of gastrointestinal irritation with oral nonsteroidal anti-inflammatory medications.  Based upon the medical records, there are other appropriate alternative oral medications that may be beneficial for this patients chronic pain.  In acute and chronic low back pain, widespread musculoskeletal pain and in peripheral neuropathic pain syndromes, the current evidence does not support the use of topical nonsteroidal anti-inflammatory medications.  Lin and colleagues performed a meta-analysis of randomized controlled trials comparing topical nonsteroidal anti-inflammatory medications with placebo. They found that topical nonsteroidal anti-inflammatory medications were superior to placebo in relieving pain due to osteoarthritis only in the first two weeks of treatment.  The current medical evidence does not support the requested medication in this clinical setting.  All told, Flector patch is not medically indicated for the treatment of 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested growth hormone therapy with Nutropin AQ NuSpin for treatment of the enrollees growth hormone deficiency.  Two physician reviewers found that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. This patient is more than two standard deviations (SD) scores below the corresponding mean height for his age. His original IGF-1 levels were low for his chronologic age. Several studies have demonstrated that growth hormone therapy generally increases height velocity acutely and may increase adult height in children. The United States Food and Drug Administration (FDA) approved growth hormone therapy with the indication for children with current height below -2.25 SD of the mean, in whom the epiphyses are not closed, and whose expected adult height is less than 63 inches (160 cm) for boys and 59 inches (150 cm) for girls. Furthermore, there are limitations of provocative growth hormone testing such as the reliance on arbitrary definitions of what constitutes a subnormal response to stimulation and the limited value in discriminating between normal short children and children with partial growth hormone deficiency. In this clinical setting, the patient fits the criteria for growth hormone deficiency and growth hormone stimulation testing is not indicated. Final Result: Two reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in pediatrics with sub-specialty certification in pediatric endocrinology and is actively practicing. One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in pediatric endocrinology 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.