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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for air ambulance services provided for treatment of the enrollees status post stroke with resultant quadriplegia. Findings:  The physician reviewer found that the air ambulance transport from California to Florida to receive long-term care was not medically necessary. The patient has quadriplegia due to a stroke, who requires long-term care. She underwent acute rehabilitation after the stroke and then returned to live with her family as her caregivers. After an episode of respiratory failure she was stabilized and plans were made for long-term care in a facility rather than at home. She did not have an acute medical issue at the time of her transport by air ambulance. The medical literature shows that air travel has health risks. Medical monitoring can be provided with a ground ambulance. The medical records do not show that the route taken by a ground ambulance would lead to a delay in case of emergency relative to transport in an air ambulance where a medical emergency would necessitate arranging an unplanned landing then transfer to a ground ambulance. Air ambulance travel did not present a favorable risk-benefit profile compared to ground ambulance. As such, the air ambulance services provided was not medically necessary for transport to receive long-term care. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that stimulant medication is considered the gold standard pharmacologic intervention for patients with ADHD. Concerta is a methylphenidate based product that was approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD in 2000. Concerta is a central nervous system psychostimulant that exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. This patient was previously treated with a Concerta and has a proven track record of tolerability and efficacy with Concerta. Additionally, upon returning to care for her ADHD, Concerta was prescribed by the treating provider at a safe, appropriate and conservative dose. As such, the requested Concerta is supported as medically necessary for treatment of this patients ADHD. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the gene test (Foundation One) for evaluation of the enrollees anaplastic astrocytoma. Findings:  2/3 of the physician reviewers found that the utility of the Foundation One testing has not been demonstrated to improve patient outcomes as compared to standard testing. According to the National Comprehensive Cancer Network (NCCN), to demonstrate clinical utility of panel genetic testing such as Foundation One, prospective randomized clinical trials are needed that compare the strategy of targeted treatment based on panel results with standard of care. The available literature on clinical utility consists of a small number of uncontrolled studies, and non-randomized controlled trials that use imperfect comparators. This evidence is not sufficient to make any conclusions on clinical utility. As a result, the use of expanded mutation panel testing for targeted treatment in cancer should only be conducted in the setting of a clinical trial. For these reasons, the Foundation One test provided was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: 2/3 of the reviewers determined that the testing at issue was 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) services for treatment of the enrollees functional impairments. Findings:  The physician reviewer found that the documentation does not demonstrate that this patient has needs for SNF services. The patient does not require SNF services to prevent a deterioration in her condition or skilled nursing services to establish a safe and effective maintenance program. The records do not reveal that the patient requires skilled therapy services on a daily basis or skilled nursing services on a daily basis. In addition, the patient has not made significant functional gains in prior skilled therapy and therefore would not be expected to make measurable gains within a reasonable and predictable period of time. She does not require inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living or establish a safe maintenance program. The patients therapy needs can be met at a lower level of care such as long term care or home with 24-hour caregiver support. All told, SNF services provided were not and are not medically necessary for treatment of this patients medical condition. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Percocet 5/325 mg one tablet every six hours as needed and physical therapy for treatment of the enrollees neck, shoulder and back pain. Findings:  The physician reviewer found that based on the documentation submitted for review, Percocet 5/325 mg one tablet every six hours as needed has not been established as medically necessary for treatment of the patients medical condition. In this case, the patient presents with a number of medical problems, including psychiatric behaviors. She has long history of seeking narcotics for pain. Due to the patients chronic non-cancer pain and addictive history, the request for Percocet is not clinically indicated. However, physical therapy as an adjunctive measure for treatment of the patients reports of pain is medically necessary. In patients with pain syndromes, there is a role for physical therapy to help function and mobility to improve quality of life. As such, the request for physical therapy is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. 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 reimbursement and prospective authorization and coverage for the percutaneous tibial nerve stimulation (PTNS) provided for treatment of the enrollees urinary incontinence. Findings:  The 3 physician reviewers found that this patient is symptomatic with urgency frequency and urgency incontinence. The etiology of her symptoms has not been established. She was placed on neuromodulation with PTNS. However, the records do not demonstrate that the patient has had a thorough evaluation with urodynamics as other etiologies including interstitial cystitis should be considered. PTNS is considered to be an appropriate salvage therapy for patients with intractable irritative lower urinary tract symptoms according to the American Urological Association (AUA) guidelines. All told, the PTNS provided was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The 3 reviewers determined that the service at issue was not and 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 reviewer number one is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Xifaxan for treatment of the enrollees irritable bowel syndrome with diarrhea. Findings:  The physician reviewer found that The records document that this patient has IBS-D, for which Xifaxan has been proven effective. In addition, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. Moreover, Xifaxan has been demonstrated to be safe and effective in randomized placebo controlled trials for IBS-D. In the TARGET-3 trial of over 1,000 patients, Xifaxan 550 mg three times daily was effective with significant symptom improvement. The American College of Gastroenterology guidelines state that Xifaxan is effective for use in this clinical setting. This patient has already been treated with medications including Imodium, Flagyl, vancomycin, and Dificid without success. For these reasons, the request for Xifaxan is supported as medically necessary for the treatment of this patients IBS-D. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Zepatier 50/100 mg for treatment of the enrollees hepatitis C virus. Findings:  The physician reviewer found that according to 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 recommendation applies to all patients, regardless of fibrosis stage. Immunity to hepatitis B is not recommended by guidelines as essential prior to hepatitis C treatment. Although reactivation of hepatitis B can occur during hepatitis C therapy, this patient has not had hepatitis B infection in the past.  The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment with Zepatier is supported as medically necessary for the treatment of this enrollees 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a procedure for treatment of the enrollee's keratoconus without scarring right eye. Findings: All three physician reviewers found that Intacs are intrastromal corneal ring segments that are implanted in the deep corneal stroma to modify the corneal curvature. This technology was first used to treat myopia and then adopted for the treatment of keratoconus. The purpose of Intacs is to reduce corneal steepening and thereby improving best corrected visual acuity. In 2004, Intacs was given a U.S. Food and Drug Administration (FDA) Humanitarian Device Exemption for use in keratoconus. Corneal cross-linking is a procedure used to slow or stop the progression of corneal thinning in keratoconus and post-refractive ectasia. The procedure was approved by the FDA in 2016. In this patients case, the implantation of the Intacs implants in the right eye for the treatment of patients keratoconus was indicated. However, the cross-linking procedure that was performed using the Holcomb C3-R system is not FDA approved. The standard FDA approved therapy for cross-linking is with the Avedro KXL system. In addition, there is a lack of peer-reviewed studies confirming the efficacy of the epithelial-on Holcomb C3-R system. Given these findings, the Intacs performed was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy, while the remaining codes were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that a portion of the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology and are actively practicing. The reviewer 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 authorization and coverage for Norco and Lidoderm patches for treatment of the enrollees lower back pain. Findings:  The physician reviewer found that there is a lack of support for the medical necessity for the requested medications in this clinical setting. Chronic pain that has no hope for a cure is considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in the documentation available for review, no objective treatment goals for pain and function are noted for the requested medications, and several requirements for opioid prescribing have not been documented.  Thus, the need to use them as the primary medication treatment strategy for pain has not been established. Additionally, it not clear what type of injections have not been helpful for her back pain. Also, other interventional procedures for treatment of pain coming from arthritic joints have not been noted. It is also unclear that this patient has initiated physical therapy for treatment of her pain symptoms. Behavior therapy is also an option for chronic pain and would help avoid medications and injections. Finally, not all medications classes have been optimized for her pain.  As such, the medical necessity for Norco and Lidoderm patches, as the next best step for pain control in the back and her arthritic joints, has not been established. Final Result: The reviewer determined that the requested medications 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 authorization and coverage for Zepatier for treatment of the enrollees 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 (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 recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with regimens including Zepatier when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Thus, Zepatier is medically necessary in this patients case. 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.