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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that the patient is independent with household ambulation and her mobility deficits could be addressed with a cane or walker.  She does not otherwise have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity and exercise, moreover, are generally appropriate and recommended for conditions such as chronic obstructive pulmonary disease, diabetes, obesity, hypertension, and back pain, and for general musculoskeletal health.  All told, the requested power wheelchair is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested equipment 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 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 Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive, non-cirrhotic genotype 1a patients should be treated with Harvoni for 12 weeks, or with Viekira Pak and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al; Poordad, et al). Although treatment of hepatitis C is necessary, based on the available medical literature, none of the information supplied in this case provides medical justification to support coverage of Harvoni over Viekira/ribavirin. No head-to-head clinical trials have compared these medications, meaning that the trials for each medication cannot be directly statistically compared due to lack of uniform study population. Based on the information provided, the patient does not have severe anemia, pregnancy, psychiatric disorders, or other medical contraindications to ribavirin (Dusheiko, et al). For these reasons, the requested treatment with Harvoni  is not supported as medically necessary for the treatment of this patients hepatitis C infection.   Final Result: The reviewer determined that the requested medication is not 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines report that patients with cirrhosis are highest priority for therapy. Per guidelines, genotype 1b patients with cirrhosis who have failed Sovaldi-based therapy should be treated with a different regimen, such as Harvoni. Ribavirin for 24 weeks and Viekira Pak is not recommended. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure (Osinusi, et al; Reddy, et al). For cirrhotic patients who have failed Incivek, the AASLD/IDSA guidelines do not recommend Viekira Pak. For this reason, Viekira Pak is not medically necessary for the treatment of this patients hepatitis C infection.  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 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 Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of the 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anterior optical coherence tomography for evaluation of her medical condition.   Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  In order to evaluate the angles of the eye in a glaucoma suspect, gonioscopy is generally performed.  The angles are graded as to how open or closed they are, and this is documented.  This determines potential future treatment of the patient.  Anterior segment optical coherence tomography can provide very high resolution images of the angles, which can help in this regard, but it is generally not performed if gonioscopy is done.  All told, the anterior optical coherence tomography was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Two 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:   All three reviewers are board certified in ophthalmology 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 Otezla for the treatment of his plaque psoriasis. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The medical records note chronic plaque psoriasis.  The Health Plan has denied coverage for Otezla due to a failure to demonstrate lack of efficacy or contraindications to preferred systemic treatments.  This patient has tried and failed therapy with a couple of medications and/or treatments.  However, there is no documentation that the patient has failed therapy with a number of other medications available for the treatment of this medical condition. Trial and failure of these agents is appropriate prior to initiation of Otezla. As such, there is a lack of support for the requested medication in this clinical setting. Thus, Otezla is not medically necessary 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 dermatology 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 insertion of a lumbar artificial intervertebral disc for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. In this case, the patient presents with chronic radicular lower back pain. Given the multilevel degenerative disease noted on imaging and findings suggestive of nerve root compression, the requested insertion of a lumbar artificial intervertebral disc 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a hospital stay for treatment of her medical condition. Findings:  The physician reviewer found that the services at issue have not been established as medically necessary in this clinical setting. The patients altered mental status (AMS) had resolved.  The patient was tolerating an oral diet and medications, she was voiding without problems and was ambulating independently. The laboratory studies were unremarkable. The physical exam was normal. According to Uptodate.com, confusional states can take days to weeks to manage.  Because delirium may require weeks or months to fully resolve, management often extends into subacute settings. In this case the patients AMS had resolved. Thus, the patient was stable with improved symptoms and lab studies, she could have safely been discharged for further outpatient care.  Given the above, the services at issue were not clinically indicated for the treatment of the patients medical condition. 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Bioness L300 foot drop system electrical stimulation (FES) device for treatment of the enrollees foot drop secondary to multiple sclerosis (MS).  Findings:  Two physician reviewers found that evidence based research and medical literature support the use of FES in this patients case. This patient has had MS, with residual spasticity and foot drop. The patients foot drop continues to impair gait, with frequent falls despite use of an ankle foot orthosis (AFO). The medical literature shows that foot drop gait is known to be inefficient, with increased fatigue and slowed walking speed. Research on the use of FES has shown potential benefit in speed of walking and oxygen uptake in patients with spasticity from chronic central nervous system (CNS) lesions, as occur in MS, stroke, traumatic brain injury, or spinal injury. Studies have also shown potential for neural plasticity, with functional gains maintained after discontinuation of FES. In this patient, a trial of FES demonstrated benefits beyond standard therapy with an AFO, and thus FES is likely to be more beneficial than standard modalities.   Final Result: Two reviewers determined that the requested device is 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: One reviewer is board certified in neurology and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation 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 Habit Reversal Therapy (HRT) for the treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence supports the requested services in this clinical setting.  HRT emerged as a therapeutic intervention in the early 1970s.  HRT is becoming more common as it is a recommended treatment not only for tics, but for trichotillomania and excoriation disorder as well.  HRT is a structured package of clinical interventions, the most important of which is the application of a competing response whenever the patient notices either a tic or the urge to tic.  HRT is typically delivered with 8 to 11 individual sessions lasting 60 to 90 minutes each.  According to the medical literature, HRT has the strongest empirical support, among the behavior therapies, for reducing tics.  HRT is classified by the American Psychological Association as a well-established treatment for Tourettes syndrome.  It is reasonably expected that HRT will improve the patients condition.  All told, the requested services 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 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:  The parent of an enrollee has requested general anesthesia for treatment of the enrollees dental condition. Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is 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.  However, in this patients case, there is no clear documentation of the need for extensive dental work and/or mouth oral rehabilitation. There is no clear documentation of an examination by the dentist who is planning to treat this patient.  There is no documentation of a previous attempt or attempts at dental examination or attempts to provide dental care with any dentist or provider without success.  There is no documented evidence of a dental treatment plan.  Thus, there is a lack of support for the requested services in this clinical setting.  All told, the requested general anesthesia 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 anesthesiology with sub-specialty certification in pediatric 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 Supartz injections for treatment of her osteoarthritis of the knee. Findings:  The physician reviewer found that evidence based medical studies conclude that hyaluronic acid is the best pharmacologic intervention for knee osteoarthritis. Hyaluronic acid was found to be better than injected placebo or injected corticosteroids (Bannuru et al). Kotevoglu and colleagues conducted a randomized controlled clinical trial comparing the effectiveness of different molecular weight hyaluronan solutions in the treatment of knee osteoarthritis. The hyaluronic acid groups performed better than placebo. Evidence based medical guidelines and peer-reviewed literature support the use of hyaluronic acid injections for this patients condition. She presented with significant and function-limiting right knee pain. Clinical exam findings were consistent with imaging evidence of tri-compartmental osteoarthritis. There was evidence of reasonable and/or comprehensive non-operative treatment and failure, including aspiration and intra-articular steroids. She was intolerant to oral anti-inflammatory medications and Tylenol was insufficient. A series of Supartz injections was performed previously with documented reduction in pain. Given the efficacy of the Supartz injections, a repeat course of the therapy is medically appropriate and indicated at this time. Therefore, the services at issue were and are medically necessary for the 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 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: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy for treatment of the enrollees behavioral health condition. Findings: Three reviewers found that the medical research indicates that behavioral health therapy including ABA is very effective for patients with ASD. Early and intensive ABA can improve cognitive, adaptive and communication outcomes. However, at this time, there is a lack of information in regards to an upper age limit for ABA services. A randomized trial found that behavioral health therapy including ABA was effective for disruptive behaviors in school age children with ASD. In addition, Minshawi and colleagues showed that ABA is effective for the treatment of self-injurious behaviors. There is also research showing that maladaptive behaviors including self-injury can continue into adulthood in children with intellectual disability or autism. In this case, the patient has maladaptive behaviors and has shown progress in several areas with the ABA he has received. Moreover, there is a lack of research indicating that autism symptoms cease at age 18 or that ABA should stop at a specific age. Thus, ABA services at the proposed frequency should continue for this patient.   Final Result: Three reviewers 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: One physician reviewers is board certified in pediatrics and is actively practicing.  One physician reviewer is board certified in child neurology and is actively practicing. One Physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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.