Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the lumbar medial branch surgery for treatment of his chronic low back pain. Findings:  Three physician reviewers found that the lumbar medial branch surgery performed on 12/13/16 was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a paucity of peer-reviewed published studies supporting the procedure at issue. The studies available are case series and observational. There is a lack of published randomized controlled trials comparing cooled radiofrequency ablation to the standard radiofrequency approach. Final Result: The reviewers determined that the procedure at issue was 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: Reviewers 1, 2, and 3 are board certified in anesthesiology with sub-specialty certification in pain medicine and is 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for mental and substance abuse residential treatment services provided from the date of service in question, forward.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records do not document suicidal or homicidal ideation or psychosis during the dates in dispute.  She had continued symptoms of depression and had not engaged in any self-harm behaviors. She was not displaying significant or severe behavioral problems while in the residential treatment center.  The records indicate that this patient needs additional treatment to further improve her social functioning, mood and behaviors.  However, per the records, she no longer needs the restrictiveness of a residential treatment facility, as she has stabilized enough to transition to a less restrictive setting.  Outpatient treatment and least restrictive options are considered first lines of care.  There are benefits to in-home therapy due to the involvement with family as well as generalization of learned skills in a natural setting.  All told, mental and substance abuse residential treatment services provided from the date of service in question, forward were not and are not medically indicated for the 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 physician reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for Victoza. Findings:  The physician reviewer found that Victoza is a glucagon-like peptide-1 receptor analog (GLP-1 RA). Glucagon-like peptide-1 (GLP-1) based therapies affect glucose control through several mechanisms, including enhancement of glucose dependent insulin secretion, slowed gastric emptying, and reduction of postprandial glucagon and of food intake. Victoza is indicated in the treatment of diabetes mellitus and obesity. One study demonstrated that GLP-1 is associated with inappropriate increase in insulin secretion, and this mechanism is responsible for post-bariatric hypoglycemia. Based on these findings, use of Victoza may cause worsening of the patients post-bariatric hypoglycemia. 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 endocrinology, diabetes and metabolism and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential level of care. Findings:  The physician reviewer found that, although chemical dependency services were indicated based on the records provided, the records do not document the medical necessity of residential level of care. The patient was discharged from a detoxification facility.  She was motivated for treatment.  She was psychiatrically stable.  She had safe and sober housing.  She had no history of local treatment and was not engaged in clinical services during the episode of illness.  Thus, there was no evidence that a less restrictive setting, following a successful detoxification, would have been unsafe or inadequate at the time. However, intensive outpatient programming was and is medically necessary in this case.  The patients addictive illness was central to her daily routine and contributed to significant impairment across multiple domains of functionality.  Despite occupational discord, relationship struggles, and two prior treatment attempts, the patient was unable to achieve significant periods of sobriety.  This patient had not consolidated treatment gains during a brief admission for detoxification.  Thus, intensive outpatient program treatment was and is reasonably expected to improve the patients condition and prevent a more serious episode of illness via relapse.  In sum, residential level of care was not medically indicated.  However, intensive outpatient program level of care from (30-day treatment program) was and is medically indicated for the treatment of this patient. Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ampyra 10 mg. Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. Ampyra is indicated for patients diagnosed with multiple sclerosis. There is a lack of sufficient peer-reviewed literature supporting Ampyra for the treatment of patients with hereditary spastic paraplegia. A study included 12 patients and reported encouraging results. Another study included five patients and showed improvement in gait speed. In addition, to the small sample population, there is a lack of placebo controlled trials supporting Amprya in this clinical setting. Therefore, Ampyra 10 mg has not been established as medically necessary in this clinical setting.  Final Result: The reviewers 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: Physician reviewer number one 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for heartburn surgery. Findings:  Three physician reviewers found that the efficacy of TIF has been demonstrated by randomized controlled trials. However, the data is contradictory. One large randomized trial including 60 patients found no improvement in esophageal acid exposure compared with baseline at 12 months; normalization of pH was accomplished in only 29% in conjunction with deteriorated valve appearances at endoscopy and resumption of PPIs in 61%. The study concluded that no long-term objective reflux control was achieved.  The American College of Gastroenterology guidelines for treatment of GERD report that the usage of current endoscopic therapy or TIF cannot be recommended as an alternative to medical or traditional surgical therapy (moderate level of evidence). The Society of American Gastrointestinal and Endoscopic Surgeons reported that numerous published series have reported significant adverse events and that there is a lack of sham-controlled trials comparing TIF with anti-reflux surgery. Studies concluded that further studies are required to define optimal techniques and most appropriate patient selection criteria, and to further evaluate device and technique safety. These conclusions are bolstered by recent reports of severe adverse events during the procedure and the need for surgery to revise ineffective TIF. Furthermore, high-quality clinical trial data in patients with prior Nissen fundoplication are limited. For these reasons, the requested transoral incisionless fundoplication along with anesthesia to tighten the wrap is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: 3 of 3 reviewers determined that the requested surgery 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: 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: 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 intensive outpatient program (IOP) services provided from date of dispute  forward and another psychiatric evaluation while in treatment. Findings:  The physician reviewer found that the records provided for review document that this patient showed no post-acute withdrawal symptoms. She was not a danger to herself or others, she was not gravely disabled, and she was medically stable. Her bipolar symptoms were not controlled. However, the patient was not medicated except for Seroquel and she was refusing other medications. She was insightful and aware of her addiction problems, and demonstrated motivation to remain sober via her active engagement in the recovery process. Overall, this patient did not require IOP level of care, rather, she could have been safely and effectively managed at the outpatient level of care. Given the recidivistic nature of her condition with multiple relapses and subsequent treatments, she already had a groundwork of relapse prevention education. There is no evidence to suggest that additional IOP treatment would have provided further benefit. Although the patient needed a psychiatric evaluation, this can be conducted on an outpatient basis and did not require provision in the IOP setting. As such, IOP services provided from date of dispute forward and another psychiatric evaluation while in treatment 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 psychiatry with sub-specialty certification in addiction 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 reimbursement for the monitored anesthesia care (MAC) services provided during a colonoscopy. Findings:  The physician reviewer found that according to the American Society of Anesthesiologists (ASA), an essential component of MAC anesthesia is the anesthesia assessment and management of a patients actual or anticipated physiological derangements or medical problems that may occur during a diagnostic or therapeutic procedure. In addition, the ASA guidelines note that a providers ability to intervene to rescue a patients airway from any sedation-induced compromise is a prerequisite to the qualifications to provide MAC services. Further, MAC is a physician service that is distinct from moderate sedation due to the expectations and qualifications of the provider who must be able to utilize all anesthesia resources to support life and to provide patient comfort and safety during a diagnostic or therapeutic procedure. Final Result: The reviewer determined that the services at issue were 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 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 Harvoni for 12 weeks for treatment of her chronic hepatitis C virus genotype 1a. 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. 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 (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.   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 authorization and coverage for intraoperative radiation therapy.  Findings:  Three physician reviewers found that there is a lack of medical literature demonstrating that treatment with intraoperative radiation therapy offers a clinical benefit compared to conventional radiation therapy techniques for breast cancer.  Furthermore, current guidelines state that two clinical trials revealed that the risk of recurrence was higher with intraoperative radiation therapy than with standard treatment with whole breast radiation.  In sum, the requested intraoperative radiation therapy is not likely to be more effective than other treatment alternatives in this patients case. Final Result: 2 of 3 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 physician reviewers 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 radiofrequency neurolysis. Findings:  the reviewers found that the documents note a history of sciatica leg pain that improved. However, there is no documentation of facet joint pain and the cause of the patients back pain remains unclear. Further, there are no imaging studies that show only facet arthritis. Final Result: The reviewers determined that the requested procedure 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 are board certified in orthopedic surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Epclusa for 12 weeks for treatment of  her chronic hepatitis C virus genotype 3a. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. This applies regardless of fibrosis stage. Per the guidelines, Epclusa for 12 weeks is recommended as first-line therapy for treatment-naive genotype 3 patients. This is based on the ASTRAL-3 trial for Epclusa, which showed a high cure rate (98%) with this regimen (Foster, et al). The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  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 reimbursement for the catheter-based impedance pH monitoring test performed.  Findings:  The physician reviewer found that according to the American College of Gastroenterology (ACG) guidelines, pH testing with impedance may be useful in evaluation of endoscopy negative patients with complaints of heartburn or regurgitation despite treatment with proton pump inhibitor therapy in whom documentation of non-acid reflux will alter clinical management. The American Society for Gastrointestinal Endoscopy (ASGE) states that pH testing combined with impedance can identify whether the reflux is acidic or non-acidic, and can provide correlation between reflux episodes and symptoms to help guide management, which can be useful in patients with persistent symptoms on proton pump inhibitor therapy who have non-acid reflux as a cause for symptoms. However, no information is provided regarding whether this patient has symptoms despite acid suppression or prior endoscopy results. These guideline requirements are underscored in current medical literature, which does not support the utility of pH testing combined with impedance in this clinical setting. Final Result: The reviewer determined that the testing at issue was not medically necessary for evaluation 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.