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 chronic hepatitis C virus genotype 1b.  Two physician reviewers found that the patient has chronic hepatitis C virus and has an advanced stage disease as she has progressed to cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines that set the standard of care in managing and treating patients with hepatitis C virus recommend treatment for all patients except those with a limited life expectancy due to non-liver-related conditions. Based on the available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has hepatitis C virus genotype 1b and is treatment naive. Hence, per the current guidelines, the requested Harvoni is medically necessary for treatment of this patients medical condition. Final Result: Two reviewers 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested magnetic resonance imaging (MRI) of the back and neck spine without dye for evaluation of her neck and back pain with decreased range of motion and radiation of pain to the right leg. The physician reviewer found that based on the available documentation, an MRI of the lumbar spine without dye is medically necessary for further evaluation of this patients complaints. This patient continues with the same symptoms referable to her low back at which time a positive EMG revealed possible lumbar spine compromise. MRI was recommended at that time and not done. Thus, this exam is considered medically necessary. However, neurological exam does not document cervical radicular signs or symptoms to support an MRI of the cervical spine. Moreover, the presence of pain and decreased range of motion are not indications for MRI of the cervical and thoracic spine under the National Imaging Associates (NIA) clinical guidelines. Thus, an MRI of the lumbar spine without dye is medically necessary, while an MRI of the cervical and thoracic spine is not medically necessary for evaluation of this patients medical condition. Final Result: The reviewer determined that a portion of the requested services is 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 diagnostic radiology 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 nasal surgery (removal of nose polyps, inferior turbinate resection, repair of nasal septum, irrigation of the maxillary sinus, exploration of the sinuses and removal of ethmoid sinus) for treatment of her sinusitis. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested surgery. The American Academy of Otolaryngology Head and Neck Surgery define clinical sinus disease with nasal polyps as that of chronic rhinosinusitis and suggests appropriate medical therapy prior to any consideration of surgical intervention. The evidence-based peer-reviewed literature suggests medical therapy be performed prior to consideration of surgical intervention. In this case, there is a lack of documentation demonstrating medical therapy has been attempted or trialed on this patient. The medical records lack documentation of medical therapies utilized to help restore normal sinus activity. A CT scan of the sinuses confirms evidence of inflammatory partially obstructive sinonasal disease with presence of polypoid degeneration. However, the history of the patient's symptoms is not documented in the medical records. Moreover, the submitted documentation does not show evidence of functional nasal airway blockage by any nasal septal deviation. The CT scan report did not state that there was any severe obstructive nasal septum. For this reason, the indications for nasal septal reconstruction are not met. Turbinate reconstruction can be considered in patients with severe hypertrophy or allergic manifestations, but in this case based on the clinical examination there is no evidence of any enlargement of the turbinates or obstructive nature of them. As such, turbinate surgical intervention is not indicated. Based on the medical literature cited above and the documentation submitted for review, the request for nasal surgery (removal of nose polyps, inferior turbinate resection, repair of nasal septum, irrigation of the maxillary sinus, exploration of the sinuses and removal of ethmoid sinus) is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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 otolaryngology and head and neck 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 Subsys sublingual spray for treatment of her rheumatoid arthritis.  The physician reviewer found that according to the current evidence-based literature, Subsys sublingual spray is used for the management of breakthrough cancer pain in opioid tolerant patients. The clinical records submitted for review indicate that this patient has been utilizing the medication due to pain from rheumatoid arthritis. The clinical records submitted for review showed no indication that the patient has any form of cancer pain. Therefore, the requested Subsys sublingual spray is not recommended to treat this patients condition. As such, the requested medication, Subsys sublingual spray, is not medically necessary for treatment of the patients rheumatoid arthritis. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of digital breast tomosynthesis to the standard digital breast mammographic may result in decrease in call backs and increase in detection of small tumors.  Per the medical literature, the addition of tomosynthesis to standard mammographic views is more advantageous than digital mammography alone.  All told, breast tomosynthesis was likely to have been more effective than other modalities for evaluating this patient.  Final Result: Three reviewers determined that the services at issue were 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 diagnostic radiology 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 treatment at an inpatient level of care for treatment of her depression, eating disorder, and anoxic brain injury. The physician reviewer found that this patient is complicated and represents a treatment failure from her residential treatment center program. She also did not tolerate medications well and required medical and nursing supervision to monitor them. She remained suicidal during the period of her treatment. In addition, she remained passively suicidal at the time of discharge. Her affect remained constricted, she was not eating, and she was poorly communicative. These are all risk factors for possible self-harm if not closely monitored. Therefore, the treatment at the inpatient level of care was medically necessary for treatment of this patients medical condition. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a peripheral bone density test for evaluation of her osteoporosis.  Three physician reviewers found that the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Fractures are the most dangerous aspect of osteoporosis and can lead to acute and chronic pain. While primary osteoporosis, which occurs with aging and accelerates at menopause, is the most common cause of osteoporosis, there are numerous secondary causes of osteoporosis as well. Hyperparathyroidism, as such, can lead to severe osteoporosis associated with a catabolic destruction of the skeleton with bone loss, brown tumors, bone cysts, and subperiosteal bone resorption of the phalanges. Because the catabolic action of parathyroid hormone predominantly occurs in cortical bone, greatest reduction in BMD is typically found at the distal 1/3 radius. Therefore, it is important for patients with hyperparathyroidism to be screened for osteoporosis. As such, the testing at issue was likely to be a more beneficial for evaluation of the patients medical condition than standard medical therapy.  Final Result:  Three reviewers determined that the testing 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 endocrinology and metabolism 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested iStent surgery for treatment of her glaucoma. Three physician reviewers found that in the peer-reviewed medical literature, Wellik and Dale demonstrated that the micro-bypass stent is a relatively safe procedure, with limited complications and no serious adverse sequelae. Samuelson and colleagues reported that pressure reduction on fewer medications was clinically and statistically significantly better one year after iStent with cataract surgery versus cataract surgery alone, with an overall safety profile similar to that of cataract surgery alone. Craven and colleagues found that patients with combined single trabecular micro-bypass stent and cataract surgery had significantly better intraocular pressure control on no medication through two years when compared to patients who underwent cataract surgery alone. All told, the data indicates the iStent surgery was likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that 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 overturned.  Credentials/Qualifications: All three reviewers are board certified in ophthalmology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested neuropsychological testing for evaluation of her cognition.  The physician reviewer found that neuropsychological testing was medically necessary for evaluation of the patients medical condition. According to the American Academy of Clinical Neuropsychologys practice guidelines, distinctive features of neuropsychological evaluations and consultations in assessing brain function and dysfunction include the use of objective neuropsychological tests, systematic behavioral observations and interpretations of the findings based on knowledge of the neuropsychological manifestations of brain-related conditions. In this case, during an appointment with a neurologist, the patient expressed concern of cognitive decline which was impacting her daily functionality. The examination included a Montreal Cognitive Assessment which was suggestive of mild cognitive impairment. Thus, further assessment was reasonable and clinically indicated based on the subjective reports, objective findings and current practice guidelines. Considering that a neuropsychologist often plays an important role in establishing the presence of a neurocognitive disorder, the differential diagnosis, quantification of impairment and cognitive strengths and weaknesses, the testing at issue was safe, appropriate, and consistent with good medical practice. Based on the documentation provided, neuropsychological testing was medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the testing at issue was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested mitochondrial electron transport chain testing for evaluation of the enrollees cyclic vomiting, hypotonia, and speech delay. Two physician reviewers found that the evaluation and treatment of mitochondrial disease was reviewed in a recent consensus statement from the Mitochondrial Medicine Society. The data demonstrates that skeletal muscle is one of the preferred tissues for doing biochemical analysis or mitochondrial DNA sequencing because tissue-specific alterations may not be present in blood. Muscle and/or liver biopsies should be performed in the routine analysis for mitochondrial disease when the diagnosis cannot be confirmed with DNA testing. This review supports the utility of biochemical studies on muscle as the standard recommendation in the evaluation of suspected mitochondrial disease. Consistent with these findings, the requested mitochondrial electron transport chain testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers determined that the requested testing is 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:  One reviewer is board certified in pediatrics and medical genetics and is actively practicing.  One reviewer is board certified in neurology, child neurology and pediatrics with a sub-specialty certification in neurodevelopmental disabilities and is actively practicing.  One reviewer is board certified in clinical genetics and clinical biochemical genetics with a sub-specialty certification in pediatrics and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency department services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. The patient states he sought immediate medical attention because he was concerned about the abnormal shape and appearance of his penis. Based upon the submitted medical records, the patient had not sustained any trauma and was not in any pain. He was not taking any medication associated with priapism. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required medical attention on an immediate basis.  In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with a partial erection with no reported trauma or pain. On physical examination the findings were minimal with a slight enlargement of the base of the penis compared to the shaft. The documentation does not support that a prudent layperson would seek immediate medical attention for swelling at the base of the penis. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.   Final Result:  The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in emergency 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 Xiaflex for treatment of his Peyronies disease.    The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has been diagnosed with Peyronies disease.  Intralesional injection therapies for patients with Peyronies disease seek to reduce plaque production, contracture, and improve on recurrence rate and progression.  However, at this time, the most effective treatment is surgery.  While there is data suggesting intralesional injection with Xiaflex may be beneficial, the findings are preliminary and further investigation is necessary to confirm long-term efficacy.  As noted in a study by Egui Rojo and colleagues, although Xiaflex has been approved by the U.S. Food and Drug Administration for the treatment of Peyronies disease, the long-term effects and results need further investigation, with large follow-up series. The current medical evidence has not demonstrated the long-term efficacy of Xiaflex in this clinical setting, and complications from injection may limit repeat treatments.  Therefore, Xiaflex is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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.