Persius/hicric huggingface dataset:
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested services provided on an emergent or urgently needed basis.  Review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a history of paroxysmal supraventricular tachycardia that resulted in symptoms prompting presentation to an emergency department at some unspecified time. However, based on the documentation submitted for review there is no evidence of syncope, significant hypotension, coronary ischemia or other acute change during supraventricular tachycardia. Paroxysmal supraventricular tachycardia can often be effectively managed with medication, and an ablation for paroxysmal supraventricular tachycardia is generally considered an elective procedure in the absence of the above urgent associated conditions. Further, the disputed services were not obtained on an immediate basis and were scheduled following the patients pre-ablation procedure. Based on the patients presenting complaints and symptoms as well as the length of time that transpired before treatment, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services in question did not meet prudent layperson criteria for emergency care or urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in cardiology 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 partial hospitalization program (PHP) services for treatment of the enrollees amphetamine type substance use disorder severe, obsessive compulsive disorder (OCD), and bulimia nervosa.   The physician reviewer found that this patients records demonstrate that she meets the criteria for continued treatment at the PHP level of care. However, her non-compliance and relapse may require intensification of her treatment. Factors that indicate that support treatment at the PHP level of care include significant interference with addiction recovery efforts with intense emotional and behavioral difficulties. Moreover, her social functioning is moderately impaired and she has not made progress at lower levels of care. She also does not indicate a readiness for change and requires significant staff support to continue in treatment. She is at high risk of relapse, and has already relapsed after prior termination of treatment at the PHP level of care. All told, the medical records support PHP services for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 skilled nursing facility rehabilitation for treatment of the enrollee, who is status post transcatheter aortic valve replacement.  The physician reviewer found that health outcomes following aortic valve replacement surgery are often significantly compromised.  Factors predictive of poor physical health outcomes following this surgery include significant heart failure, arthritis and living alone.  Nevertheless, cardiac rehabilitation programs are generally safe and effective following this type of surgery.  In this patients case, she would be a candidate for community-based (i.e., home or outpatient) rehabilitation to restore her conditioning and improve her function.  However, she does not require inpatient rehabilitation.  There are no indications in the available records that she requires inpatient level hospital care for rehabilitation, nursing or medical conditions.  Hospital level care to provide 24-hour supervision and custodial level assistance for self-care and mobility needs is not medically necessary.  This can be provided in a nursing home or other custodial level care facility.  All told, the requested skilled nursing facility rehabilitation 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 physical medicine and rehabilitation 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 Zyvox for treatment of her medical condition.  The physician reviewers found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient had intraoperative culture results which indicated the presence of a Staphylococcus epidermidis infection that is not resistant to either oxacillin or vancomycin.  Per the current medical evidence, indications for the use of linezolid (Zyvox) do not include use for nonresistant strains of this infection.  In addition, this patient was recently on a three-week course of this medication and has continued symptoms.  There is some question regarding whether the use of antibiotics with chronic rhinosinusitis is always indicated, and this patient does not appear to be on sufficient allergy medication regimen.  All told, the requested medication Zyvox  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 otolaryngology 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 Dexilant for treatment of his gastroesophageal reflux disease (GERD).  The physician reviewer found that this patient reports that his GERD symptoms have been treated for several years with Dexilant. However, his records do not include pathology from an endoscopy that shows GERD or Barrets esophagus. In addition, the records do not indicate that he has been on Dexilant for the past year or that he has tried and failed other proton pump inhibitors. Absent this documentation, the patient should be treated with standard proton pump inhibitors to determine whether he can adequately control his symptoms before being treated with Dexilant. Accordingly, the requested Dexilant is not medically necessary for treatment of this 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 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 transcranial magnetic stimulation for treatment of her major depressive disorder.  The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  This treatment modality tends to be well-tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There is sufficient evidence in the peer-reviewed medical literature to support the use of transcranial magnetic stimulation in this clinical setting.  In this case, the patient has pursued other standard therapies.  Considering the medical records and the expanding peer-reviewed literature base, the requested transcranial magnetic stimulation 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 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 a 3T magnetic resonance imaging (MRI) of the prostate for evaluation of his localized prostate cancer. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for 3T MRI of the prostate has not been established. According to the American Urological Association (AUA) guidelines for the management of clinically localized prostate cancer an ideal regimen for active surveillance has not been defined but could include periodic repeat prostate biopsies to assess for sampling error of the initial biopsy as well as for subsequent progression of tumor grade and/or volume. The National Comprehensive Cancer Network (NCCN) guidelines include recommendations for prostate biopsy at specific intervals. For active surveillance and observation for individuals with clinically localized prostate cancers who are candidates for definitive treatment, follow-up should include needle biopsy and repeat prostate biopsy if PSA increases. Furthermore, the AUA and NCCN guidelines do not recommend 3T MRI in surveillance protocols. For the reasons provided, the patients request for 3T MRI of the prostate is not medically necessary. Final Result: The reviewer determined that the requested diagnostic procedure is 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested 12 weeks of Harvoni is supported as medically necessary for treatment of this patients hepatitis C virus infection. 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 coronary computed tomography angiography (CTA) for evaluation of his chest pain.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for the coronary CTA has not been established. Coronary CTA is a reasonable option for patients with a low to intermediate pretest probability of coronary artery disease who are unable to perform an exercise test, a pharmacologic nuclear stress test, or stress echocardiography. In this case, the patient presented with atypical chest pain and underwent pharmacological stress test which revealed a fixed inferior defect without any evidence of reversibility. Given the pharmacological stress test did not reveal ischemia, the coronary CTA was not clinically indicated. For the reasons provided, the services at issue were not medically necessary. 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 cardiology with sub-specialty certification in interventional cardiology 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 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested 12 week course of Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus. 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested Prometheus Anser IFX testing for evaluation of her Crohns disease.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determining the cause of symptoms while on therapy is not clear.  The use of Prometheus Anser IFX testing to investigate response and direct subsequent management has not been proven to improve patient clinical outcomes or alter patient management.  The effectiveness of the services at issue in the management of Crohns disease compared with conventional courses of action remains unproven in controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response, nor have threshold levels been established.  All told, the superior efficacy of Prometheus Anser IFX testing has not been established. Final Result: Three 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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested a special wheelchair for treatment of her cerebral palsy.  Findings:  The physician reviewer found that the medical records document the patient has spastic quadriplegia with progressive problems attributed to positioning issues with her existing custom wheelchair. The nature of cerebral palsy suggests that changes in posture due to altered spasticity are reasonably expected. Based upon the diagnoses provided and the current use of a custom wheelchair, a custom wheelchair is medically necessary. There are notes which indicate that a vendor for the wheelchair reportedly told the patients parent that a new wheelchair is needed and that the existing wheelchair cannot be adjusted. Based upon the presence of spastic quadriplegia and the information provided by the vendor concerning the need for a new wheelchair, this request for a new custom wheelchair is appropriate. Thus, the requested special wheelchair is supported as medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested a custom knee brace for treatment of her medical condition status post anterior cruciate ligament (ACL) reconstruction with allograft. Findings:  The physician reviewer found that it is medically necessary for this patient with stated XXX syndrome and clinical findings of generalized ligamentous laxity to have the protective benefits of a custom knee brace. This has been recommended for a period of one year after ACL reconstruction. The patient has XXX syndrome, which is characterized by a wide range of effects including variable musculoskeletal syndrome. Due to the documentation of a generalized ligamentous laxity combined with the stated XXX syndrome, it is prudent for this patient to have the benefit of ACL bracing during rehabilitation. Custom ACL bracing is not medically necessary in patients who do not have collagen disorders. In the medical literature, an evaluation of 820 skiers who had experienced ACL injuries and reconstruction was performed. Of the 820 patients, 257 of the skiers used functional bracing during skiing and 563 skiers did not. The authors reported a statistically significant increase in incidence of subsequent knee injury in non-braced skiers. Consistent with the current scientific data, it is medically necessary for this patient to have the requested custom knee brace for ACL bracing during rehabilitation. Final Result: The reviewer determined that the requested device 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 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.