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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90-400mg medication, one tablet daily, for 12 weeks. Findings:  The physician reviewer found that according to the recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment naive, genotype 1 patients should 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 approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni 90-400mg medication, one tablet daily, 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 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 has requested authorization and coverage for Lysteda. Findings:  The physician reviewer found that there is support in the medical literature for the requested medication in this clinical setting. Lysteda is approved by the U.S. Food and Drug Administration (FDA) for the treatment of heavy menstrual bleeding. A review notes that, Tranexamic acid represents an option for treatment of women with HMB (heavy menstrual bleeding) who do not desire or should not use hormonal treatment. Tranexamic acid is an antifibrinolytic agent that competitively blocks the conversion of plasminogen to plasmin, thereby reducing fibrinolysis. Tranexamic acid was approved by the US FDA for the treatment of HMB in 2009; Studies have found that tranexamic acid reduces menstrual blood loss by 26 to 54 percent in women with HMB and in comparative studies was more effective than NSAIDs. The study also discusses the use of nonsteroidal anti-inflammatory drugs (NSAIDs) stating the following, `A systematic review of randomized trials of women with HMB concluded that NSAIDs were more effective than placebo at reducing HMB, but less effective than the LNg20 and tranexamic acid. The literature supports the use of Lysteda for treatment of menorrhagia. The records indicate that Lysteda has already worked in this patient.  Moreover, this patient has tried and failed oral contraceptives. She has also used ibuprofen throughout her cycle without benefit. She does not have any contraindications to the use of Lysteda. For the reasons stated above, Lysteda is medically necessary for treatment of this patients medical condition. 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 obstetrics and gynecology 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 reimbursement for the dopamine transport (DAT) single photon emission computed tomography (SPECT) scan. Findings:  The physician reviewers found that the DAT SPECT scan provided was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the testing at issue in this clinical setting. Several studies support DAT SPECT to be utilized to differentiate between Parkinsons disease and essential tremor. In this case the patient presented with some features of Parkinsons disease and essential tremor. As such, the DAT SPECT scan was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the diagnostic procedure at issue was 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: All three physician reviewers are board certified in neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement and prospective authorization and coverage for partial hospitalization program (PHP) from the date of service in question, forward. Findings:  The physician reviewer found that the documentation submitted does not support the medically necessity of the services at issue in this clinical setting. In cases such as this, an evidence-based, objective, instrument such as the spell out Level of Care Utilization System for Psychiatric and Addiction Services is indispensable in determining necessary level of care for adults, to insure their level of care meets their individual needs, safely and effectively, in the least restrictive setting possible. The literature suggests that outpatient treatment with modalities such as cognitive behavioral therapy can be effective for treatment of eating disorders. The progress notes indicate that this patient was cooperative in treatment. She was noted to be providing good cooperation while in therapy at the PHP level of care. She did not display any dangerous behaviors while in the PHP. The patient had no significant history of substance use or abuse. The documentation provide indicates that she is able to receive 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. As such, in this patients case, she could have been treated in a less restrictive setting. For the reasons stated above, PHP from the date of service in question, forward were not and are not medically necessary for treatment of this patient. 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 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 Nexium and Benicar. Findings: The physician reviewer found that the request for Nexium and Benicar has been established as medically necessary for treatment of the patients medical condition. Based on the records provided for review, the patient has increased cardiovascular risk, cerebrovascular disease and both hypertension and acid reflux that have been managed long-term with Benicar HCT and Nexium. In this circumstance, continued use of these medications as the patient transitions to a new primary care provider is reasonable and appropriate. Since a temporary lapse in these medication may be severely detrimental to the patients health continued coverage of her medications is 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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for inpatient hospitalization services.  Findings:  The physician reviewer found that the review of the submitted clinical documentation reveals that the patient remained gravely disabled with a delusional thought complex while nursing notes documented evidence of impaired reality testing and active internal stimuli.   While the acute episode of illness that prompted the admission had improved, due to the considerable impairment and poor prognosis, a premature discharge would have increased the patients morbidity and the chances of a prompt re-admission, while exposing the general population to a potential risk of harm.  Since the patient remained significantly disabled and a definitive placement at an appropriate alternative level of care had not been arranged, continued stay at the acute inpatient hospitalization level of care was medically necessary to facilitate suitable disposition to a less restrictive, residential treatment setting.  An additional five business days of acute inpatient placement would have been reasonable to transition the patient to a residential treatment facility. Accordingly, service delivery at the inpatient hospitalization level of care was safe, appropriate and consistent with good medical practice. Thus, inpatient hospitalization services  were medically necessary for treatment of this patients condition. Final Result: The reviewer determined that a portion  inpatient hospitalization services were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: Physician reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic anti-reflux surgery utilizing LINX reflux management system (esophageal sphincter augmentation device). Findings:  The physician reviewers found that the medical evidence supports the requested services in this patients case.  Appropriate patient selection is crucial before anti-reflux procedures.  In this patients case, the records document that the patient has undergone an appropriate preoperative assessment.  The LINX device is an appropriate option for the management of medically refractory gastroesophageal reflux disease.  This patient has gastroesophageal reflux disease based on pH recordings.  Per the records, she has not benefited to a significant degree from multiple combination acid suppression treatments.  As such, she can be considered medically refractory to acid blocker drugs.  The available records do not document contraindications to implantation of the LINX device. Therefore, the requested laparoscopic anti-reflux surgery utilizing LINX reflux management system is likely to be of greater benefit than other treatment options. Final Result: 2 of 3 reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three physician reviewers 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for stereotactic body radiotherapy (SBRT). Findings:  The physician reviewer found that as noted by the National Comprehensive Cancer Network (NCCN), the standard treatment for patients who have a rising PSA following radiation therapy is with hormone therapy or chemotherapy. There is a lack of evidence to suggest that a course of SBRT will improve outcomes in patients with prostate cancer . In some cases, patients with colorectal or lung histologies with limited metastatic disease may be eligible for SBRT. However, there is a paucity of medical evidence that suggests that patients with prostate cancer benefit from SBRT. The standard of care for patients with prostate cancer is systemic treatment with hormone therapy or chemotherapy. Accordingly, the requested SBRT is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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: Physician reviewers 1,2 & 3 are board certified in radiation 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for accelerated partial breast irradiation.Findings:  The physician reviewer found that the patient presented for a screening mammogram . The study indicated calcifications. The core biopsy demonstrated a grade II ductal carcinoma in situ (DCIS) that was estrogen receptor positive. Breast magnetic resonance imaging (MRI) did not show any other lesions. She is planning for lumpectomy and the possibility of using accelerated partial breast irradiation (APBI) as her adjuvant therapy. The patient is requesting coverage for  APBI. The Health Plan denied this request stating that the requested services are investigational for the treatment of this patients medical condition. There is evidence in the medical literature for the efficacy of the requested services in this clinical setting. The American Brachytherapy Society (ABS) in 2013 and the American Society for Radiation Oncology (ASTRO) in September 2016 noted, With regard to DCIS, more than five publications have now documented the efficacy of APBI in patients with DCIS including a pooled analysis of 300 patients. In light of these findings, DCIS has been included in acceptable histologies.  ASTRO/ABS included patients with low-risk DCIS in their selection criteria for APBI. Per the Radiation Therapy Oncology Group (RTOG) 9804 study, they suggest the following selection criteria for APBI: screen-detected, low to intermediate nuclear grade, less than or equal to 2.5 cm size, and resected with margins negative at greater or equal to 3 mm . Although final pathology from the proposed lumpectomy will dictate treatment options, this patient fulfills the selection criteria recommended by ASTRO/ABS and the RTOG 9804 study for APBI. Upon review of available data, APBI should be considered as a standard treatment option based on the recommendations from the ABS in 2013 and ASTRO in September 2016. In sum, APBI will likely be more effective than the standard available modalities for treatment of this patient.Final Result: The 2 of the 3 reviewers determined that the services at issue were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers 1, 2 & 3 are board certified in radiation 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin (IVIG). Findings:  The physician reviewer found that the medical literature does not support the use of IVIG in this clinical setting. A study  performed a dose-finding trial of two different doses of a new formulation of immunoglobulin for suppression of both clinical and magnetic resonance imaging (MRI) disease activity as well as safety. The authors concluded that this study did not substantiate a beneficial effect of IVIG in doses ranging from 0.2 to 0.4 g/kg. This result seriously questions the utility of IVIG for the treatment of relapsing-remitting multiple sclerosis. Similarly, the study for secondary progressive MS states that Treatment with IVIG in this study did not show any clinical benefit and therefore cannot be recommended for patients with secondary progressive multiple sclerosis. In this case, the patient has been treated with Copaxone. However, there is no mention that the patient has been treated with other highly active U.S. Food and Administration (FDA) approved therapies for disease modification such as Gilenya, Tysabri, Lemtrada, or Zinbryta. Thus, there are multiple disease modifying agents that are more effective than Copaxone, and likely to be effective in treating the patients progressive MS. As such, the request for IVIG is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1,2 & 3 are board certified in neurology and is actively practicing. The reviewers 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 authorization and coverage for methylprednisone. Findings:  The physician reviewer found that in the documentation available for review, although the patient gives an extensive history of multiple medical conditions, the patient does not currently have one of the diagnoses listed by the U.S. Food and Drug Administration (FDA) for the use of methylprednisolone taper. In addition, studies noted that no data on the efficacy and safety of systemic corticosteroids in residual pain in inflammatory arthritis could be identified from the literature. Moreover, the patients records do not include a thorough physical examination and complete treatment plan for her conditions. Such a work-up may include seeing a rheumatologist and possibly being started on different medications that do not have the same side effect profile as methylprednisolone. All told, the requested methylprednisone 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 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 reimbursement for outpatient transitional living center day treatment program services for treatment of the enrollees thoracic myelopathy with spastic incomplete paraparesis. Findings:  The physician reviewer found that the outpatient transitional living center day treatment program services were not medically necessary for treatment of this patients medical condition. The documentation indicates that the patient was able to ascend and descend 25 stairs, ambulate with a front wheeled walker with some spastic gait, transfer into his wifes car, and perform toilet transfers with modified independence. A transport wheelchair was ordered and the patient used a temporary chair until his customized chair was complete and delivered to his residence. Per documentation, all durable medical equipment (DME) and home accessories were delivered to the patient. The patient was offered continued outpatient rehabilitation services but refused and remained at the outpatient transitional living center day treatment program. The patients rehabilitation needs no longer required the patient to remain at the outpatient transitional living center. His functional level was safe for discharge to home, there was extensive patient and spouse safety and training prior to discharge. The patients home accessories and DME were complete. The patients needs could have safely and effectively be met upon discharge to home and if needed, further therapy could have been performed on an outpatient basis. Additionally, the patient could continue to follow up with his physiatrist for any continued rehabilitation medical needs. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.