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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of her medical condition.   The physician review found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The current medical evidence does not support the requested services in this clinical setting.  The peer-reviewed medical literature provides evidence for epidural steroid injections in documented cases of nerve root compression or radiculitis.  The patients physical examination does not show evidence of radiculitis, and her chronic pain condition is not consistent with this diagnosis.  All told, the requested epidural steroid injections are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus (HCV). Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The recommendation by the AASLD/IDSA is not to deny patients treatment if they have early stage disease, but to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. As such, the daily fixed-dose combination of ledipasvir /sofosbuvir for 12 weeks as recommended by AASLD/IDSA guidelines for treatment-naive patients with HCV genotype 1a infection is medically necessary. 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One  reviewer is board certified 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Pegasys for treatment of her essential thrombocythemia.  The physician reviewer found that essential thrombocythemia is a myeloproliferative disorder caused by specific mutations in the hematopoietic stem cell.  Essential thrombocythemia manifests as a very high platelet count, which predisposes patients to abnormal clotting.  The mainstay of treatment is reduction of the platelet count using hydroxyurea, anagrelide, or interferon. Pegasys is an alternate formulation of interferon that has less toxicity.  The current medical evidence shows that it can reduce the platelet counts of patients with essential thrombocythemia.  There is sufficient support for the requested medication in this patients case, and it is a standard agent used in myeloproliferative disorders.  All told, the requested Pegasys is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 medical oncology 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 Hyqvia subcutaneous infusions for treatment of the enrollees immune deficiency. The physician reviewer found that primary immunodeficiencies are a group of disorders that have in common defective antibody production, rendering those affected with recurrent bacterial infections.  One type of immunodeficiency is IgG subclass deficiency.  Patients with IgG subclass 3 deficiency can experience recurrent respiratory infections, and treatment involves immunoglobulin administration.  Hyqvia is a subcutaneously administered immunoglobulin product indicated for treatment of primary immunodeficiency. The hyaluronidase is used as a facilitating agent to allow large volumes of fluid to be absorbed subcutaneously.  The rate of adverse events is lower than with parenteral administration of intravenous immunoglobulin.  This patient has a longstanding history of atopic disease requiring multiple routine and rescue medications as well as recurrent sinusitis.  Based on the current literature, she would benefit from administration of Hyqvia, a subcutaneous hyaluronidase-facilitated IgG infusion.  All told, the requested Hyqvia subcutaneous infusions are 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 pediatrics with sub-specialty certification in pediatric critical care 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Genotropin for treatment of the enrollees growth hormone (GH) deficiency.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. According to the documentation submitted for review, the patient meets criteria for GH deficiency, and GH therapy is clinically indicated. However, a change specifically to the brand Genotropin is not medically necessary. Rather, the vehicle of administration of the GH should be changed to improve adherence to therapy and allow for accurate administration of the prescribed dose. The Health Plans preferred formulary brands of Saizen and Humatrope are both appropriate and reasonable in this clinical setting and the patients parents can be taught how to administer either Humatrope of Saizen via syringe and vial, which will bypass the technical difficulties that ensued with use of the Easy Pod device. Based on the medical literature cited above and the documentation submitted for review, the request for Genotropin is 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 pediatric endocrinology 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 mental health residential treatment center services for treatment of the enrollees behavioral health condition.  The physician reviewer found that the mental health residential treatment center services were and are medically necessary for treatment of the patients medical condition. Based on the documentation provided, specialty services at the residential level of care were and are indicated for this patient struggling with the developmental stage of identity formation who has yet to consolidate the treatment gains necessary to succeed in a less restrictive setting. Further, considering her previous suicidality and acute psychiatric hospitalizations coupled with her suboptimal family situation, a conservative treatment course is to be expected.  The developmental perspective is a key component of consideration. This patient demonstrates unrefined intrapsychic defenses, self-defeating coping strategies and a fragmented sense of self which manifests with defiance, impulsivity and ambivalence.  This patient evidences struggles in achieving a healthy second individuation, with role diffusion championing, and a complete lack of formal operational thought.   The psychiatrist noted the patients anger, anxiety and limited interpersonal skills, and increased one of her medications. This patient lacks the psychological maturity to succeed in a less restrictive environment. In sum, the services in dispute were and are reasonably expected to improve the patients condition and prevent a more serious episode of illness. Furthermore, a three-month residential admission followed by step-down to a partial hospital program would be consistent with community practice standards in a case such as this. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program (PHP) services for treatment of her major depression, anorexia nervosa and alcohol abuse. The physician reviewer found that the American Psychiatric Association (APA) treatment guidelines recommend that PHP should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. Further, the APA noted that PHP may be appropriate for patients that remain at high risk for relapse and lack sufficient motivation to continue in treatment, have severe psychiatric comorbidity and/or a history of relapse to substance. Hay and colleagues reported that PHP has the advantages of increased intensity of care (and supported or supervised meals) found in inpatient services. It also has an argued increased preservation of personal autonomy and life activities that are associated with outpatient care.   This patients hepatitis and pancreatitis are of primary concern as she has spent much of the past year between admissions and she has been unable to adhere to her lifesaving meal plan without recurrence of symptoms, as is the chronic relapsing course of eating and substance disorders. Consistent with these findings, the PHP services were and are supported as medically necessary.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 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 inpatient pain management for treatment of the enrollees chronic pain syndrome.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for inpatient pain management has not been established. In this case, the patient has non-malignant chronic pain. Methadone may safely be weaned by an experienced pain management provider or addictionologist as an outpatient. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain. Opiates are considered adjunctive to this therapy and at that point controlled release narcotics if indicated with close monitoring by a certified pain management physician is recommended. The weaning opioids should always be the goal and the provider should closely monitor the patient during this time. Inpatient care is not required. For the reasons provided, inpatient pain management for six weeks is not medically necessary for treatment of the patients medical condition.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral sacroiliac joint fusion or radiofrequency for treatment of the enrollees bilateral sacroiliac joint pain.  Three physician reviewers found that the requested services are not likely to be of greater benefit than other treatment options.  The documentation submitted for review indicated previous sacroiliac injections were 100% successful in controlling the patients pain and the pain relief lasted for two months.  However, there was no indication the patient continued to have facet joint pain, signs and symptoms on the physical examination.  Details regarding previous conservative therapy, such as medication, physical therapy, spinal manipulation therapy, epidural steroid injections, or other interventions, were not provided for review.  The current medical evidence does not support the requested services in this clinical setting.   Final Result: Three reviewers determined that requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery 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 Afrezza inhaled insulin for treatment of his diabetes.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Insulin remains an essential element for diabetes treatment and is the sole treatment for patients with type 1 diabetes.   Recently, new insulins are being developed which provide alternative treatment options to human insulin.  Along with newer synthetic insulins, innovative insulin delivery methods, such as oral or inhaled insulin, are being developed with the aim to reduce insulin-associated hypoglycemia, lower intraindividual pharmacokinetic and pharmacodynamic variability, and improve imitation of physiological insulin release.  Afrezza in combination with basal long-acting insulin has showed favorable reduction of glucose levels and hemoglobin A1C.  It may be particularly promising for patients who cannot tolerate injections of rapid acting insulin.   Although this patient has subjective complaints with regard to the discomfort of injections, the records do not document objective evidence of nerve damage.   He will still need to be on the basal insulin injection, even if he does not require bolus injections of insulin.  All told, the requested medication Afrezza inhaled insulin is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 a residential treatment center (RTC) for treatment of the enrollees mood disorder and conduct disorder.  The physician reviewer found that the patient is described as being cooperative and fully participating in individual, group, and recreation therapies. There were no documented medical issues, and his medications had remained stable for at least two months. He had some limited insight into his issues. However, he was not a danger to himself or others, he was able to fully perform all activities of daily living, and was cooperating in all therapeutic modalities. He did not meet criteria for stay in the RTC level and could have been safely discharged to a lower level of care.   Therefore, the medical records do not support the medical necessity of the RTC services at issue.  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 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 Oxycodone for treatment of her shoulder pain. The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Moreover, Ballantyne and colleagues reported that prolonged use of high dose opiates might induce tolerance and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. Therefore, it would be in the best interest for the patient to start a multidisciplinary program. All told, the medical necessity of the requested mediation has not been established in this clinical setting. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Subsys for treatment of his centralized intractable pain. The physician reviewer found that subsys is not medically necessary for treatment of the patients medical condition. Current standard of care for chronic pain associated is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anti-convulsants and anti-depressants considered adjunctive to this therapy. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In the retrospective study by Baron and McDonald, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Furthermore, prolonged use of high dose opiates might induce tolerance and abnormal pain sensitivity. Therefore, the patients request for Subsys is not medically necessary. 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.