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

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  In this case, upon presentation the residential setting was reasonably expected to improve the patients condition and prevent a more serious episode of illness.  Subsequently, relapse prevention efforts and therapy to consolidate family issues and recurrent interpersonal strife remained indicated, the patient had no acute psychiatric issues or medical comorbidity.  There was no interpretative summary articulating the clinical rationale for continued residential services beyond the initial projection.  Based on his progress in the program, there was no evidence to suggest that transition to a less restrictive setting would have been inadequate.  Thus, the residential treatment center services at issue were medically necessary initially, but not thereafter.Final Result: The reviewer determined that 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi, Daklinza and Ribavirin for 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the American Association for the Study of Liver Disease/Infectious Diseases Society of America (AASLD/IDSA) guidelines represent the standard of care in this setting. According to the AASLD/IDSA guidelines for the retreatment of persons in whom prior therapy has failed, the following therapy is recommended for patients with HCV genotype 3 infection with cirrhosis in whom prior treatment with Peginterferon and Ribavirin has failed: daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 24 weeks along with weight-based Ribavirin. Since the patient has already failed prior therapy, his only treatment option based on the above nationally-recognized guidelines is the proposed 24-week course of Sovaldi, Daklinza and Ribavirin. As such, the requested medications are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-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 Harvoni for 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines recommend equally efficacious treatment options for patients with HCV genotype 1a or 1b infection who have compensated cirrhosis, in whom prior peginterferon and ribavirin treatment has failed. Per guidelines, daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 24 weeks is recommended as a Class I, Level A rating. In addition, daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir (Viekira Pak) and weight-based ribavirin for 24 weeks is recommended as Class I, Level A rating. Viekira Pak is U.S Food and Drug Administration (FDA) approved and indicated for the treatment of adult patients with genotype 1 (GT1) chronic HCV infection, including those with compensated cirrhosis. Limitation of Use: Viekira Pak is not recommended for use in patients with decompensated liver disease.  The available records do not support absolute contraindications by the patient for the use of Viekira Pak.  All told, the medical necessity of Harvoni for 24 weeks has not been demonstrated.  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 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 Euflexxa injections for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  Researchers performed a meta-analysis of 137 studies with 33,243 participants and concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Another study conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  All told, the requested Euflexxa injections are medically indicated 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 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 right anterior total hip replacement surgery for treatment of her medical condition.   Findings: The physician reviewer found that the submitted documentation supports the requested services in this patients case.  Sciatic nerve injury is a greater risk in the posterior approach.  The anterior approach has been associated with earlier functional recovery and shorter stays in the hospital attributed to the muscle sparing properties of the anterior approach.  There is sufficient support for the requested services in this clinical setting.  All told, the requested right anterior total hip replacement surgery is medically indicated 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested artificial cervical disc replacement utilizing the Mobi-C artificial disc for treatment of his neck pain. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Based on the documentation submitted for review, the patient has chronic neck pain and arm pain and numbness that have not improved after artificial disc placement. In addition, the U.S. Food and Drug Administration (FDA) have required a seven year post approval study to determine the long term safety and effectiveness of the Mobi-C device. Thus, the long-term safety and effectiveness of this product has not been substantiated. All told, the requested services are 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: Two reviewers are board certified in neurological surgery and are actively practicing. One reviewer is board certified in orthopedic surgery 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 Sumatriptan Succinate, quantity 75, for treatment of her migraine headaches.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication quantity. Per U.S. Food and Drug Administration (FDA) guidelines the maximum dosage of Sumatriptan in a 24-hour period is two doses, due to the potential for vasospasm which may cause stroke or myocardial infarction, and the development of serotonin syndrome for those patients who are on selective serotonin reuptake inhibitors (SSRI) drugs. The use of triptans more than three days a week is likely to cause medication overuse headache, whereby headache occurs in the absence of the offending acute therapy. This has been well documented with the use of triptans. The use of greater than two Sumatriptan injections a day on a daily basis is not the standard of care, and places the patient at risk for not only escalating headache, but cerebral and coronary vasospasm which could be life threatening. The approval of Sumatriptan Succinate quantity 75 is excessive, potentially places the patient at risk, and not medically necessary for treatment of the patients medical condition.  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 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 Daklinza with Sovaldi for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines also recommended 12 weeks of Sovaldi, ribavirin and peg-interferon.  The Health Plan has offered coverage for Sovaldi, ribavirin and peg-interferon.  In this patients case, the alternative offered by the Health Plan is an appropriate regimen.  Therefore, Daklinza with Sovaldi for 12 weeks are not medically indicated for the treatment of this patient.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 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 guardian of an enrollee has requested general anesthesia for dental procedures for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the request for general anesthesia for dental procedures is medically necessary in this clinical setting. General anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice. General anesthesia is often employed to facilitate extensive dental treatment particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting. The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for pediatric patients. A medical study reviewed and collected data from general anesthesia records for over 700 patients over a two-year period. The utilization of general anesthesia allowed for comprehensive and high quality dental care. This was particularly applicable in cases of young patients who required extensive dental treatment. The study explains the rationale for endorsement of general anesthesia by the American Academy of Pediatric Dentistry. This includes the ability to facilitate dental treatment in pediatric patients who are unable to cooperate, require significant surgical procedures or comprehensive oral care. In addition, this study also notes that despite the risk of adverse events, general anesthesia in a hospital operating room is considered safe, efficient and more cost effective than repeated dental visits for oral restoration. In this case, there is documentation of the need for extensive dental work and full mouth oral rehabilitation. For these reasons, the requested services are medically necessary and appropriate for 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested surgery. In this case, the patient presents with significant weight loss following bariatric surgery and as a result of this weight loss, she has excess skin of the lower abdomen that is well-documented to be associated with chronic rashes, skin irritation and significant malodor.  She has been prescribed dermatologic treatment without resolution. Although the size of her abdominal pannus is not severe, based on the overall clinical documentation from multiple providers, the patient has a typical pattern of chronic dermatologic insult associated with excess skin-to-skin contact. Chronic rashes are a functional deficit and its non-surgical treatment has failed. The requested panniculectomy is medically necessary for this patient as it would likely directly address this functional deficit. According to the medical literature The abdominal panniculus may cause disabling rashes, pain, physical limitation, back strain, and cosmetic deformity, and symptoms are more marked the heavier the panniculus. Panniculectomy can treat these symptoms. This is the case for this patient and thus, panniculectomy is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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 plastic and reconstructive 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 Harvoni for 12 weeks for treatment of her hepatitis C. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni for 12 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested acupuncture for treatment of her back pain.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. According to the documentation submitted for review, the patient presents with chronic lower back pain. The peer review literature has several quality studies supporting treatment with acupuncture in this clinical setting. A medical study performed a randomized control trial to assess acupunctures effectiveness for treating low back pain. The authors concluded that Acupuncture effectively relieves chronic low back pain. In addition, the medical literature indicated that the effectiveness of acupuncture is almost twice that of conventional therapy. Given the clinical documentation submitted for review and the support in the peer-reviewed literature, the request for acupuncture is supported as medically necessary for treatment of the patients medical condition.  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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic active hepatitis C are eligible for treatment and should be treated regardless of fibrosis score. In this case, Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C genotype 1. In addition, the patient is treatment naive with a low viral load and therefore eight weeks would be the appropriate duration. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines.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.