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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his post-cancer pain. Findings:  The physician reviewer found that chronic pain that cannot be cured is considered palliative in nature and treatment. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. Based upon the documentation provided for review, there are non-opioid treatment options that have not been utilized for this patient. There is no evidence the patient has undergone behavior therapy. In addition, there is no documentation of optimization of all non-opioid medications. For these reasons, the requested Norco is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain management and hospice and palliative 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 Tramadol, Norco and Percocet for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  Per the medical records, non-opioid treatment options have not been exhausted.  No mention of behavior therapy has been documented or done despite much research to support its use.  In addition, all non-opioid medications have not been optimized.  All told, the requested Tramadol, Norco and Percocet are not medically indicated for the treatment of this patient.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued skilled nursing facility level of care with resumption of physical therapy, occupational therapy, and speech therapy services for treatment of his medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility care has not been established. Functional impairments due to acquired brain insults such as stroke can improve with time, such as natural recovery processes, but are also amenable to rehabilitation interventions. The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature. In this case, reconditioning and ongoing rehabilitative management can be provided in a less intensive rehabilitation setting, such as in the home with supervision to custodial level assistance and community-based rehabilitative services, or in a custodial level facility.  There is a lack of documented ongoing skilled nursing needs, such as complex wound care, initiation of self-care related to enteral feeding or ostomy care, requiring ongoing inpatient care in the available records. As such, continued skilled nursing facility level of care with resumption of physical therapy, occupational therapy, and speech therapy services was not and is not medically necessary for treatment of the 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 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 an epidural steroid injection for treatment of his medical condition.    Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is no mention of a home exercise program being done in the past or how long the patient had gone to physical therapy in the past, if at all.  The literature indicates that a home exercise program after physical therapy independent of an epidural can provide lasting results.  For these reasons, the requested epidural steroid injection 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 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 Otezla 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 of the requested medication. Otezla (apremilast) is an orally administered phosphodiesterase-4 inhibitor U.S. Food and Drug Administration (FDA) approved for the treatment of psoriatic arthritis (PsA). However, Otezla is not currently known to be disease modifying at this time. As such, it is not a preferred agent for the treatment of PsA. Per researchers Treatment recommendations for peripheral arthritis include non-steroidal anti-inflammatory drugs (NSAIDs), intra-articular glucocorticoid injections, disease-modifying antirheumatic drugs (DMARDs) and [tumor necrosis factor] TNF inhibitors. Anti-TNF agents have been proven very effective for PsA and are disease modifying agents. Anti-TNF agents prevent progression of disease, erosions and disability and are thus the preferred agent for PsA. As noted above, anti-TNF agents are the preferred medication in this disease as they are known to be disease modifying which Otezla has not proven to be. In this case, the patient was in remission with her previous treatment regimen, although having gastrointestinal side effects. It would be reasonable to try another anti-TNF agent prior to authorizing Otezla as she may not have the same side effects and they have proven to work for her. Given that the patient has not failed other anti-TNF agents, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   The reviewer is board certified in rheumatology 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 intravenous antibiotics for more than four weeks for treatment of her medical condition.   Findings:  Three physician reviewers found that this patient has symptoms that do not necessarily represent the diagnosis of Lyme disease.  They are nonspecific, and there is a lack of relevant physical examination findings.  There is no Lyme antibody titer, and other laboratory findings are within normal limits. The diagnosis of late stage Lyme disease has not been established.  There is no synovial fluid for analysis for Lyme arthritis or cerebrospinal fluid positive Lyme titer to support neuroborreliosis.  If the diagnosis of late stage Lyme disease was made, the standard therapy is four weeks of intravenous antibiotic therapy.  Longer courses or repeated courses have not been shown to be efficacious in the treatment of Lyme disease.  All told, intravenous antibiotics for more than four weeks are 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:   One reviewer is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing.  Two reviewers are board certified in internal medicine 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi in combination with Daklinza for treatment of his hepatitis C. Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks, regardless of interferon eligibility. The medical evidence indicates that a delay in treatment may result in decreased survival.  No alternative regimen has been approved for treatment of hepatitis C in this case.  For these reasons, the requested Sovaldi in combination with Daklinza is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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 Sovaldi for treatment of his 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 2 patients should be treated with Sovaldi and ribavirin for 12 weeks.  These guideline 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 2 regardless of fibrosis stage. For these reasons, Sovaldi is medically indicated 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Anser IFX testing for evaluation of the enrollees Crohns disease.  Findings:  Three physician reviewers found that recent studies indicate that drug level monitoring is being used with increasing frequency to predict durability of response and to guide decision making in those not responding adequately. Literature published over the past several years increasingly points to benefits of therapeutic drug level monitoring as preventing unnecessary exposure to a drug in a futile exercise, and helping to make timely decisions regarding switching medications within the same class or to another class. Several algorithms have been proposed and a common sense approach to their use has been widely adopted. At this point, they are used routinely in centers catering to large populations of inflammatory bowel disease (IBD) patients primarily in an attempt to maximize and prolong the benefit of a very useful drug category.  One groups 10-year experience identified loss of response to infliximab in line with other studies at 12% after year one and pointed to the likely relationship to development of antibodies to infliximab (ATI). Empiric dose adjustment no longer seems reasonable in a time when data is available for guiding those decisions. This is especially true in the pediatric population where timely decision making regarding choice of drug is critical to preserving growth and decreasing the likelihood of surgery. In this case, the patient had already been through several dose adjustments and the result of the Anser IFX testing in this circumstance likely provided clinical benefit that would not otherwise have been ascertained.  Final Result: Three reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in pediatrics with sub-specialty certification in pediatric 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient psychiatric hospitalization services for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates the patient presents with a history of serious and persistent mental illness which has been poorly controlled, thus necessitating intensive services including hospitalizations. The record documents complex psychiatric comorbidity and recurrent suicidality. However, the patient was improving during the admission and it appeared that the acute psychiatric syndrome that had prompted the admission was resolving. He was actively engaged in treatment. A discharge planning meeting was held but limited records have been provided beyond that date. Overall, while the patient had progressed during the hospital stay, he had not yet consolidated the treatment gains necessary to successfully follow through with treatment in a less restrictive setting. Based on the documentation provided, it would have been appropriate and consistent with accepted medical practice to retain this patient at an acute level of care initially, at which time he could have been appropriately treated at a less intensive level of care.  Final Result: The reviewer determined that a portion of the services was medically necessary for treatment of the patients medical condition. Specifically, inpatient psychiatric hospitalization initially was medically necessary. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment center level of services for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Per the medical records, adequate services could not have been delivered in a less restrictive setting.  This patient had a very serious addictive illness complicated by a co-occurring diagnosis of major depressive disorder.  Her addictive illness dominated all domains of her life and undermined her developmental task of identity formation.  She did not have an experiential foundation to draw upon to negotiate intrapsychic and interpersonal stressors.  Further, she had failed treatment in a less restrictive setting during the episode of illness and was at high-risk for a poor outcome in the absence of appropriately matched care.  Upon admission, the patient was demonstrating symptoms consistent with a withdrawal syndrome and the record reflects a difficult detoxification.  It is more than likely that an outpatient detox would have failed and culminated in relapse.  Thereafter, the patient addressed her continued cravings, stunted insight, limited coping strategies and self-defeating behaviors by engaging the full range of services afforded by the setting.  The current medical evidence supports the services at issue in this clinical setting.  All told, residential treatment center services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 immunotherapy for treatment of her medical condition.   Findings:  Two physician reviewers found that the patient has had recurrence after treatment for her cervical cancer.  The standard of care would be chemotherapy using conventional platinum/taxane combined with bevacizumab targeted therapy.  There is a lack of medical literature demonstrating the superior efficacy of immunotherapy in this clinical setting.  Therefore, the superior benefits of the requested immunotherapy have not been established.  Final Result: Two 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 obstetrics and gynecology with sub-specialty certification in gynecologic oncology 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 rehabilitation services for treatment of his medical condition. Findings:  The physician reviewer found that adrenoleukodystrophy is pathophysiologically characterized predominantly by a non-inflammatory distal axonopathy involving mostly the long tracts of the spinal cord, resulting in a progressive spastic paraplegia. Current studies state that there is no cure for the leukodystrophies and treatment of the underlying pathology remains challenging. The patients treatment for his adrenoleukodystrophy was complicated by a stroke. He underwent inpatient rehabilitation and was discharged home. Per the submitted records, he has been undergoing rehabilitation in a residential setting. The patient is otherwise mobile at the household level without an assistive device and the community level with crutches. He is performing his self-care tasks with supervision and direction. In sum, the patient did not require continued rehabilitation services. All told, rehabilitation services were not and are not medically necessary for treatment of the 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 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.