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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for computed tomographic angiography and computed tomographic angiography chest for evaluation of the enrollee, who has a history of hyperlipidemia and glucose intolerance. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Based on the records provided, the patient presented with increased coronary risk on statin therapy and without documented symptoms or physical examination abnormalities suggestive of coronary ischemia.  In this circumstance, screening coronary computed tomography angiography is not medically necessary and is not considered standard accepted practice in the medical community. The decision to treat with a statin medication has already been made based on risk factors.  Current guidelines endorsed by several national organizations also do not recommend coronary computed tomography angiography as a screening test in this setting. 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 internal medicine with sub-specialty certification in cardiovascular disease 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 partial hospitalization level of care services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the progress notes indicate that the patient was cooperative in treatment.  However, she did have some difficulty engaging in group treatment. She reported substance cravings on several occasions.  The patient had depressive symptoms during her stay, but she did not display any dangerous behaviors while in the partial hospitalization program. Per the records, the patient could have received effective treatment on an intensive outpatient basis due to her lack of self-harm behaviors and lack of active suicidal or homicidal ideation.  The supplied documentation does not indicate that she was having severe mood swings or other severe psychiatric symptoms. Intensive outpatient programs allow individuals to remain in their own homes and communities, which may improve their adjustment to community life. 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 authorization and coverage for clonazepam dispensed on a monthly basis. Findings:  The physician reviewer found that although appropriate patient-centric care may ultimately arrive at rather uncommon medication regimens, there is no longitudinal evidence in the medical record of systematic progression through standard pharmacologic therapies, applied in conjunction with evidence-based non-pharmacologic interventions, to support the medical necessity of clonazepam therapy dosed at 6 mg daily and dispensed on a monthly basis. The patient has been diagnosed with multiple anxiety disorders. However, there is no evidence that standard therapies, such as alternative medication strategies, treatment with cognitive behavioral therapy, or chemical dependency and/or psychiatric consultation, has been exhausted. Further, the patient is prescribed multiple respiratory sedating medications, including benzodiazepine. Recognizing the recent tripling of emergency room visits and increased death rate of patients prescribed both a benzodiazepine and an opioid, the U.S. Food and Drug Administration issued a warning of the serious risks associated with the combined use of certain opioid medications and benzodiazepines. Based on the documentation provided, clonazepam dispensed on a monthly basis has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewers determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially upheld. Credentials/Qualifications: Physician reviewer number two 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 authorization and coverage for proton beam therapy for treatment of the enrollees breast cancer. Findings:  Two of the three physician reviewers found that there is a lack of sufficient data to support proton beam therapy is more beneficial than standard therapies such as photon therapy for breast cancer. The appropriate cardiac dose constraints for breast radiation are uncertain. One study suggested a 7.4% relative increase in major coronary events for each increase of 1 Gy in mean heart dose for photon therapy, with no safe threshold dose below which coronary events did not occur. In addition, there are unknown dosimetric constraints for smaller cardiac substructures such as the left anterior descending artery or left ventricle that are likely to be more clinically relevant than mean dose to the entire heart, since most of the heart dose not receive radiotherapy for breast cancer. Another concern is whether protons have the same biologic effect between different tissues. Overall, the use of proton therapy in the treatment of breast cancer remains controversial. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in radiation oncology and is 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 authorization and coverage for Zepatier 50-100 mg for 12 weeks for treatment of her chronic hepatitis C virus (HCV) genotype 1a. 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 recommendation applies to all patients, regardless of fibrosis stage. Per the guidelines, patients with extrahepatic manifestations of hepatitis C, such as those with symptomatic cryoglobulinemia as in this case, should be prioritized for treatment.  The guidelines recommend that treatment-naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for 17.2 hours per month of direct applied behavioral analysis (ABA) therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training for treatment of his autism.  Findings:  The physician reviewer found that ABA is a medically necessary intervention for the treatment of autism spectrum disorders, and remains one of the most evidence based interventions available. In this case, the patients parents are requesting continued coverage of ABA therapy to address emotional regulation, impulse control, and compliance. A treatment plan has been developed that is consistent with the patients essential health needs such as daily living and communication and consistent with the diagnosis of autism. Based on the support in the peer-reviewed literature and clinical documentation submitted for review, the medical necessity of 17.2 hours per month of direct ABA therapy, 4.3 hours per month of supervision and 8.6 hours per month of parent training provided from 11/7/16 forward was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewers 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 pediatrics with sub-specialty certification in developmental-behavioral 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier for 12 weeks for treatment of the enrollees 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 (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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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: An enrollee who has requested authorization and coverage for EpiPen two pack for treatment of the enrollee, who has allergies to nuts. Findings: The physician reviewer found that the medical evidence show that epinephrine administration is a critical component of individualized emergency action plans for patients at risk for anaphylaxis. The auto injector should be portable, identifiable, safe, and effective. In this patients case, the history and laboratory data indicate that the patient had a significantly elevated IgE level to multiple food items.  Her laboratory testing showed a class 4 reaction to walnuts, and a class 3 reaction to soybean, wheat, sesame seeds, hazelnuts and almonds. She had multiple positive results to respiratory allergens such as pollen, dust mites, and animal dander. 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 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential treatment center (RTC) services for treatment of her behavioral health condition. Findings:  The physician reviewer found that The documentation submitted does not support the medically necessity of the services at issue in this clinical setting. This patient did not have suicidal or homicidal ideations or psychosis. The records indicate that she had continued symptoms of poor interpersonal skills and periods of intense emotions but she had not engaged in any self-harm behaviors. She was not displaying any significant or severe behavioral problems during her stay. The records demonstrated that she requires additional treatment to further improve her social functioning, impulsive behaviors, and mood. However, it appears that she no longer needs the restrictiveness of a residential psychiatric treatment facility as she has stabilized enough, over the several weeks of residential care at the facility to transition to a less  restrictive setting. The treatment goals listed by the residential treatment center could be accomplished on an outpatient basis. While the treatment of the patients interpersonal skills will likely require longer-term treatment due to her autism spectrum disorder diagnosis, it would not be expected that these interpersonal skill deficits would be resolved during residential treatment. Outpatient treatment and least restrictive options are considered first lines of care as referenced by The American Academy of Child and Adolescent Psychiatry. The guidelines recommend that children and adolescents be treated in the least restrictive setting possible and to maintain and foster natural supports. Children should be treated in the setting that is least restrictive and disruptive to their lives. The medical literature supports inpatient or residential treatment for children who have not responded to efforts at outpatient level of care.  Moreover, there is strong data to suggest that there are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  Studies have shown that treatment outside of a residential setting are effective and are as beneficial as RTC programs.  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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in dosage of fentanyl from 175 mcg to fentanyl 250 mcg for treatment of her fibromyalgia, neuropathy, and bilateral sacroiliac joint dysfunction. Findings:  The physician reviewer found that in this clinical setting, the recommendation to maintain the patients pain medications at 175 mcg is well supported by the medical literature. Dose escalation is not a long term plan but a short term plan for the treatment of tolerance. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this case, there is no medical evidence based rationale given for the increase in dosage by the provider. There must be a risk and benefit analysis in order to justify the requested increase in dose of fentanyl from 175 mcg to fentanyl 250 mcg. It is unclear what the plan is for any unseen future pain results the patient would experience while already on over 600 morphine milligram equivalents (MME)/day. In addition, according to the records, this patient may have built a tolerance to this medication therapy since the start of the narcotics. The patients pain scores have remained the same despite increases in the amount of opioid she is taking. Her pain level was 4/10 when she was taking 330 MME/day and was also 4/10 on 495 MME/day. There was no documentation to show that her pain levels had improved and there were no changed objective functions noted with this 165 MME/day increase. As such, the objective goals, with this high of a dose of opioid, have not been established. There were no records to show that all non-pharmacological therapies have been performed or even addressed. There were no mention of behavior therapy despite much research to support its use. 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. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for positron emission tomography (PET) scan for evaluation of the enrollees ovarian cancer stage I. Findings:  Two of the three physician reviewers found that the patient who presented with pelvic discomfort associated with her menses and was found to have a right adnexal cyst on ultrasound. A CA125 was elevated. A repeat ultrasound performed 2016 showed that the cyst had increased in size from 2.3 x 1.7 x 1.7 to approximately 3.2 x 2.6 x 2.7. She underwent laparoscopic removal of the cyst with final pathology showing a clear cell carcinoma arising from a mixed serous/clear cell cystadenofibroma. The patient reported that she strongly desires fertility preservation. The patients provider ordered a positron emission tomography (PET) scan. The patient requested coverage for PET scan. The Health Plan denied the requested services as investigational for the evaluation of this patients medical condition.  Although PET scans are not routinely used for preoperative staging of ovarian cancer, there is clinical data to support its use in certain circumstances. Since this patient is young and desires fertility preservation, avoiding a larger surgery could be advantageous towards that goal. The National Comprehensive Cancer Network guidelines endorses the use of PET scan for indeterminate lesions if results would alter management. As this patient has a cancer arising from a benign cyst, it could be considered indeterminate. A positive PET scan for metastatic disease would alter her management. A PET scan is supported in this clinical setting. Final Result: The reviewers determined that the requested services at issue are 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: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An female enrollee has requested authorization and coverage for body contour surgery (bilateral thighplasty with liposuction) for treatment of the enrollees rashes and are not reconstructive in nature. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. The records document evidence of functional impairment related to moderate to severe excess skin of the bilateral medial thighs, following significant weight loss.  The patient is noted to have chronic rashes and irritation associated with the excess skin of the medial thighs which has been treated with over-the-counter powders and prescription medication. Medial thighplasty is likely to provide functional improvement in her chronic rashes. No other conservative management would likely be beneficial. Her photographs are supportive of her documented functional impairment, which show significant excess skin of the medial thighs. Thus, medial thighplasty is medically necessary for the treatment of this patient. However, the records do not establish the medical necessity of the requested liposuction. Based on the submitted photographs, there is minimal excess subcutaneous tissue.  The requested liposuction is not likely to affect her functional deficit of chronic rashes. The patients excess skin of the medial thighs constitutes an abnormal structure of the body.  However, the excess subcutaneous tissue does not constitute an abnormal structure of the body, as there is no evidence of an abnormal collection of subcutaneous tissue.  Thus, the requested liposuction is not reconstructive in nature. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Final Result: The reviewer determined that a portion of the requested services is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.