Persius/hicric huggingface dataset:
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.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. 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.  This patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to pre-existing medical conditions, which can be exacerbated by ribavirin.  For these reasons, the requested Harvoni is medically necessary 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a panniculectomy for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based on the medical records provided, there is insufficient documentation that the patient has failed reasonable conservative dermatologic treatment.  The photographs do not show a significantly overhanging lower abdominal pannus.  The time course of treatment of her functional deficits as well as specific dermatologic measures has not been provided.  There is a lack of support for the requested services in this clinical setting.  A clear functional deficit related to the mildly overhanging lower abdominal pannus that has failed reasonable conservative measures has not been adequately defined in the medical documentation.  Therefore, the requested panniculectomy 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 plastic 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 oxycodone for treatment of his medical condition. Findings: The reviewer found that there is a lack of support for the requested medication in this patients case.  Per the records, behavior therapy has been started but has not been completed despite research to support its use.  Additionally, there is a lack of documentation of optimization of other evidence-based, non-opioid medications for pain.  Rather, large doses of opioids are being used, without a clear rationale for such a high dose despite research to show the dangers of a high dose and it lacking efficacy for quality of life.  The records indicate that tolerance has taken place since the start of the narcotics.  Dose escalation is not a long-term plan, but a short-term plan for the treatment of tolerance. Moreover, the records do not discuss other standard lower extremity neuropathic pain treatments.  All told, the requested oxycodone 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 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 laboratory testing for evaluation of his medical condition. Findings:  Three physician reviewers found that the use of Anser ADA testing has not been clinically proven to improve patient clinical outcomes. The effectiveness of Anser ADA compared with conventional courses of action remains unproven.  Patients who are treated with adalimumab may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear. Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Clinical guidelines for management of inflammatory bowel disease do not recommend testing for anti-drug antibody during clinical management.  In sum, laboratory testing was not likely to have been superior over other methods of evaluation.  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:   All 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 has requested a second gastric bypass surgery for treatment of her medical condition.   Findings:  Three physician reviewers found that a review of the medical records provided indicates that this patient has already undergone gastric bypass surgery.  There is a lack of support for a second gastric bypass surgery in this clinical setting.  Perioperative compliance is essential to weight loss after Roux-en-Y gastric bypass.  Since this patient has demonstrated recurrent weight gain despite bypass, repeat bypass is not recommended by current bariatric guidelines.   Repeat bypass surgery is not standard of care and carries a high risk of dumping syndrome as well as other perioperative complications. Thus, the requested second gastric bypass surgery is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in 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 fentanyl patches for treatment of her chronic pain. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current medical evidence does not support the requested medication in this clinical setting.  This patient failed to attend pain management visits.  Additionally, all non-opioid treatment options for her chronic pain have not been utilized.  The records do not document optimization of all non-opioid medications.  There is no plan in place to monitor this patient with the requested medications from her primary doctor.  Multiple minimal requirements for opioid prescribing have not been done and the need to use this medication as the primary treatment strategy for pain has not been established.  All told, the requested fentanyl patches are 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 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 residential treatment, substance use disorder, detoxification services for treatment of his polysubstance abuse.  Findings:  The physician reviewer found that upon review of the submitted documentation, the medical necessity of substance abuse residential treatment for detoxification has not been established.  The submitted records do not document he had prior treatment at lower levels of care. Nor is there evidence the patient had attempted to withdraw unsuccessfully on his own. The patient was medically and psychiatrically stable during the admission. The staff reported that he was motivated and engaged in treatment. As such, the patient could have been safely and effectively treated on an outpatient basis, which is common practice in the community in patients with mild to moderate withdrawals. All told, the patient did not require 24-hour supervision at a residential level of care during the period at issue. Thus, the residential treatment, substance use disorder, detoxification services were not medically necessary. 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 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 minimally invasive cervical spine surgery for treatment of his medical condition. Findings: The reviewer found that the requested minimally invasive cervical spine surgery has not been established as medically necessary in this clinical setting. The patient presents with multiple medical comorbidities and multi-factorial cervical and lumbosacral anatomical changes. The requested surgery would not likely provide benefit to the patients medical condition.  The use of minimally invasive techniques is not a substitute for overall considerations of patient care. And the outcomes of any surgical intervention will be limited by difficulties in localizing the relationship between specific anatomical changes and current symptoms. Cervical myelopathy, such as changes within the spinal cord, have not been established due to patient motion. The overall efficacy of minimally invasive posterior cervical techniques is controversial. In view of the complexity and limitations in diagnoses and the presence of multiple significant organ system disorders, the requested services are not clinically indicated for the 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 specific number and dosage of Toradol tablets for treatment of her endometriosis.   The physician reviewer found that upon review of the clinical notes, the documentation fails to demonstrate the medical necessity for the requested quantity of Toradol tablets when, instead, a lesser quantity of Toradol tablets is medically necessary. Chronic pain, as evidenced by this patient, is typically multifactorial and can be very difficult to manage. Medical studies and prescribing data, as it relates to the use of Toradol beyond recommended dosage, indicate strong concerns about its effects on the gastrointestinal and nephrotic systems as well as potential for cardiac effects. There is very limited information about the safe interval between dosing schedules.  This patient desires to use Toradol daily. This is beyond the scope of the approved use of Toradol or most other non-steroidal anti-inflammatory drugs (NSAIDs). Secondly, the use of NSAIDs for chronic pelvic pain have limited benefit in long term use. Toradol, to be used on a regular basis, is not part of the long term management algorithm for endometroic pain. Additionally, this patient is also chronically on another NSAID.  All told, the Health Plans approval of Toradol at a reduced quantity is medically reasonable and appropriate in this setting. In sum, the requested quantity of the medication Toradol is not medically necessary for treatment of this patients endometriosis.  Final Result: The reviewer determined that the requested quantity of 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an office consultation with a plastic surgeon for evaluation of her hypertrophy of breast.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity for the requested consultation. The patients clinical condition warrants an evaluation by a plastic surgeon. Per the record, this patient has severe symptomatic macromastia and has failed conservative management of pain control and chiropractic treatment.  Winn and colleagues support the use of a relatively thorough evaluation with respect to macromastia. In addition, evidence-based clinical studies indicate that symptoms of macromastia can be improved by breast reduction.  The patient has well-documented chronic upper back pain and shoulder grooving directly associated with her severe macromastia. The patients condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. In summary, the patient has a functional problem that is directly related to her significant macromastia.  Breast reduction is a well-known procedure that directly addresses this functional deficit.  Therefore, a consultation with a plastic surgeon is medically necessary in the evaluation and treatment of the patients medical condition. Final Result: The reviewer determined that the requested consultation is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections at the dosage of 200 units every three months for treatment of the enrollees migraine headaches. Findings:  The physician reviewer found that medical studies support the use of greater than 155 units every three months and the general practice by the majority of headache specialists is to administer greater than 155 units. Specifically, medical guidelines allow for some customization by providers. Some studies have looked at doses higher than 155 units and these studies have found that higher doses than 155 units were more effective in treating migraine headaches. One study used 260 units and found Botox was effective; but, this same study found that at higher dosing, more side effects were noted. On the other hand, other Botox-migraine studies where 195-260 units were used; the participants had no serious adverse events. In this patients case, the dosage of 200 units every 3 months is clinically supported. Also relevant, is this patients history of receiving 200 units every 3 months for an extensive period of time with no documented adverse effects to the dosing.  In sum, the dosage of 200 units every three months are medically necessary for the treatment of this patients migraine headache.  Final Result: The reviewer determined that the requested medication and dosage 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Fentanyl for treatment of her medical condition. Findings:  The physician reviewer found that the patient presented with a history of chronic pain. The step wise WHO ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. (Raffa et al). In this patients case it does not appear all non-opioid treatment options had been utilized. Further, there was no plan in place to monitor this patients medications either historically and currently (Jamison et al). Moreover, it is unclear as to whether the diagnosis of chronic regional pain syndrome (CRPS) was supported. Based upon the information provided, the patient only appears to have met one of the criteria for such diagnosis and as noted in the medical records the patient has chronic pain syndrome and possibly fibromyalgia (Wurtman). Finally, multiple minimal requirements for opioid prescribing were not documented and the need to use Fentanyl to taper the patients opioid use is not supported. Pain specialists generally use taper medications that are not long-acting (which Fentanyl is). Rather than using Fentanyl, buprenorphine oral form or methadone would be used for tapering purposes to get off another opioid. Moreover, there is no need to actually change opioids to taper; the physician can simply start decreasing the already prescribed opioids. As such, the medical necessity of  Fentanyl has not been established.  Final Result: The reviewer determined that the medication at issue was 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: The parent of an enrollee has requested residential treatment center services and prospective future residential treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patients residential treatment was medically necessary for treatment of this patients behavioral health condition. The record also supports prospective services to treat the patients suicidal ideations. The notes reflect that the patient continued to entertain suicidal thoughts and was reported to make light of this behavior to his peers and was entertaining it readily. Studies show that one indicator of future completed suicide is the presence of prior suicide attempts.  For this case, the patient has a history of suicide attempts.  The notes reflect that the patient was openly talking about it with peers.  All told, residential treatment center services were medically necessary. Additionally, future residential treatment center services are also medically indicated for the treatment of this patients behavioral health 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.