Persius/hicric huggingface dataset:
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 400-100 mg (one tablet per day) for 12 weeks for treatment of the enrollees hepatitis C virus.  Findings:  The physician reviewer found that According to the 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 1a patients should be treated with Epclusa for 12 weeks, based on a 98% cure rate in the ASTRAL-1 trial. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment of hepatitis C is needed, and the requested treatment with Epclusa 400-100 mg (one tablet per day) for 12 weeks is medically necessary for the treatment of this patients 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 authorization and coverage for Radicava for treatment of the enrollees amyotrophic lateral sclerosis (ALS). Findings:  Three physician reviewers found that Radicava has had several double blinded clinical trials. A phase 3 trial was positive leading the U.S. Food and Drug Administration (FDA) approval of the drug for the treatment of ALS. The FDA did not specify when in the disease course the treatment was indicated. Although the initial phase 3 study with more advanced patients did not meet the primary endpoint, there was statistically insignificant slowing of disease progression in the study group. In this case, the patient has ALS that is between early and late stage disease. Given the clinical documentation submitted for review, treatment with Radicava is likely to be more beneficial for treatment of the patients ALS than any available standard therapy. Final Result: The reviewers determined that the requested medication is 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: Reviewers 1, 2 and 3 are board certified in neurology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for emergency medical services. Findings:  The physician reviewer found that the services at issue were necessary for treatment of an emergency medical condition. In this case, the patient experienced the sudden onset of dizziness with an abnormal sensation in the chest. The patient had a history of hypertension. Paramedics were called to the scene and found the patients blood pressure to be elevated. The paramedics recommended the patient proceed to the emergency department. The patients blood pressure had begun to decline on arrival, as the patient had taken one of the patients blood pressure medications. The patients presenting complaints with the blood pressure of 160/100 documented by paramedics warranted evaluation for a hypertensive emergency. This condition can lead to end-organ damage to include myocardial ischemia, acute ischemic stroke, or other potentially life-threatening conditions. Sudden onset of chest pressure and neurologic symptoms with hypertension meet guidelines for emergency services. Thus, the services provided were for emergency medical services. Final Result: The reviewer determined that the patient received emergency medical services on the date of service at issue. Therefore, the Health Plans denial should be overturned. 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: 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 the enrollees hepatitis C virus. 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, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin. Delay in treatment may result in decreased survival. 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 Repatha Sureclick 140 mg/mL for treatment of the enrollees hyperlipidemia. Findings:  The physician reviewer found that based on the records provided the patient has documented coronary disease and hyperlipidemia with both severe intolerance to statin therapy and ineffective LDL lowering with Zetia medication. In this circumstance treatment with a PCSK9 inhibitor such as Repatha is reasonable, appropriate and standard accepted therapy in the medical community. Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol. This patient fits the latter criteria since there is documented intolerance to statins and continued significant LDL elevation in spite of treatment with Zetia. There are several randomized prospective trials that document safety and outcome improvement with the use of PCSK9 inhibitors in this setting. Thus, Repatha Sureclick 140 mg/mL is medically reasonable and appropriate in this clinical setting.  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 cardiovascular disease 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: The patients parent has requested authorization and coverage for NuvaRing 0.12 mg/0.015 mg every 24 hours, two (2) per month. Findings:  The physician reviewer found that the NuvaRing is the only intravaginal hormonal contraceptive currently approved by the U.S. Food and Drug Administration (FDA). The NuvaRing is a flexible polymer ring with a 54-mm outer diameter and a 50-mm inner diameter. Its core releases a daily dose of 15 g ethinyl estradiol and 120 g of the progestin etonogestrel. These doses effectively inhibit ovulation. The NuvaRing is initially inserted within five days after the onset of menses. It is removed after three weeks for one week to allow withdrawal bleeding. After this, a new NuvaRing is inserted. However, the use of two rings per application is not FDA approved. There is a paucity of evidence in the medical literature that supports the use of two NuvaRing devices per cycle in this clinical setting. Therefore, the requested NuvaRing 0.12 mg/0.015 mg every 24 hours, two (2) per month is not medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested medication dosage is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in obstetrics and gynecology with sub-specialty certification in reproductive endocrinology 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: The patient has requested reimbursement for the residential treatment center (RTC) services provided. Findings:  The physician reviewer found that the records do not support the medical necessity of the RTC services provided to this patient. The patients post-acute withdrawal symptoms were mild. He was not suicidal or homicidal, aggressive or violent. He was medically and psychiatrically stable. He was cooperative, compliant, and participated in his treatment. There were no emotional, behavioral, or cognitive issues that would have prevented him from stepping down to a less restrictive treatment setting. He was medically and psychiatrically stable and he had a safe and supportive environment at home. His emotional difficulties, cravings, and relapse education and prevention could have been dealt with in an ambulatory level of care in conjunction with community support system.  All told, the RTC services provided were not medically necessary for treatment of this patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for brand name Vytorin for treatment of the enrollees cholesterolemia. Findings:  The physician reviewer found that Vytorin contains a combination of ezetimibe and simvastatin. Currently, there is a lack of data in the peer-reviewed medical literature supporting the use of brand name Vytorin over the generic versions. This patient states intolerance to the generic and some notes state allergy. However, there are no specific dates or medical records documenting specific outcomes with use of generic versions demonstrating intolerance. All told, this patients records do not support the medical necessity of the requested brand name Vytorin. 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 cardiovascular disease 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 treatment center services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue in this clinical setting. This patients drug use was central to his daily routine and contributed to his significant impairment across multiple domains of functionality. He had strained family relations.  He had depressive symptoms.  He had a history of medical problems secondary to his drug use, including methicillin-resistant staphylococcus aureus (MRSA) abscesses from intravenous drug use. Per the records, this patient had not consolidated the treatment gains necessary to succeed in the outpatient setting after less than a week of residential care. Two days prior to the timeframe in dispute, the patient had poor focus with difficulty articulating his thoughts, along with anxiety, depression and craving. Thereafter, according to the records provided, the patient was actively engaged in treatment during the admission, including the addition of mood stabilizing medications in his final week of the admission. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards for a case of this severity and facilitated transition to a less restrictive setting. Additionally, the services provided at the time were reasonably expected to improve his condition and prevent a more serious episode of illness. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for magnetic resonance imaging (MRI) for evaluation of right knee pain. Findings:  The physician reviewer found that In the medical literature, researchers noted in patients with knee pain, knowledge of the radiologic appearance of the abnormalities allows more accurate diagnosis of the cause of the pain including chondral abnormalities, patellar instability and dislocation, femoral trochlear dysplasia, abnormal patellar location, bipartite patella, various tendinopathies, bursal inflammation, traction apophysitis in pediatric and adolescent patients, and miscellaneous diseases including mediopatellar plica syndrome and Hoffas disease. The authors reported that MRI offers superior soft tissue contrast resolution and allows for more accurate evaluation of the underlying etiology and therefore may improve treatment and possible surgical planning. Other researchers reported that MRI is currently the modality of choice for detecting meniscal injuries and planning subsequent treatment. Thus, the literature does support the use of MRI to rule out other sources of intraarticular derangements, such as meniscal tear, for knee pain in this clinical setting. As this patients plain film x-rays have already excluded acute osseous fracture as a cause in this case, the requested MRI is supported as medically necessary for evaluation of this patients knee pain. Final Result: The reviewer determined that the requested diagnostic procedure is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested reimbursement for the gene panel testing services for evaluation of the enrollees carrier status. Findings:  The physician reviewers found that As noted by the American College of Obstetricians and Gynecologists (ACOG), early prenatal genetic testing focused primarily on Down syndrome , but now it is able to detect a broad range of genetic disorders. For this patient there are no identified family members or affected children with the diseases tested. Without documented abnormalities, the genetic screening for cystic fibrosis was indicated in this clinical setting. Accordingly, the genetic screening for cystic fibrosis portion of the genetic testing performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy, while the remaining portion of the genetic testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of 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 partially overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in obstetrics and gynecology and 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: The enrollee has requested authorization and coverage for a panniculectomy for treatment of the enrollees excess skin in the abdominal area. Findings:  The physician reviewer found that there is sufficient support in the documentation for the requested services in this clinical setting. The photographs show evidence of a significantly abnormal asymmetric lower abdominal pannus as well as significant protuberance on profile view. Additionally, there appears to be an irregular scar deformity of the lower abdomen, as well. The documentation shows a severely abnormal abdomen as the result of previous major intra-abdominal surgery. Common functional problems associated with an overhanging pannus or skin redundancy are disabling rashes, pain, physical limitation, and back strain.  In this patients case, the record supports indications for panniculectomy. Therefore, the requested panniculectomy is medically necessary for the treatment of this patients medical condition.  With regard to whether the requested services are considered reconstructive in nature, in this patients case, the abdomen is significantly abnormal and the abdominal presentation is likely the direct result of the patients previous intra-abdominal infection due to an intestinal perforation.  As such, the aim of the surgery is to create a more normal appearance and based on review of the photographs, a more than a minimal improvement would be likely. Final Result: The reviewer determined that the overturned the Health Plans denial on the basis that the requested services are medically necessary and are reconstructive in nature. Credentials/Qualifications: The reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Privigen (intravenous immune globulin (IVIG) for treatment of the enrollees chronic inflammatory demyelinating polyneuropathy (CIDP). Findings:  The physician reviewer found that although IVIG is standard treatment of CIDP, the documentation submitted for review does not support the diagnosis in this case. In general, the following criteria support the diagnosis of CIDP: progression over at least two months, weakness more than sensory symptoms, symmetric involvement of arms and legs, proximal muscles involved along with distal muscles, reduced deep tendon reflexes throughout, increased cerebrospinal fluid protein without pleocytosis, nerve conduction evidence of a demyelinating neuropathy and nerve biopsy evidence of segmental demyelination with or without inflammation. The primary goal of therapy in patients with the Guillain-Barre syndrome (GBS) and chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is improved strength and functional ability. Improvement in pain, sensory loss, gait disorder, and autonomic instability are other goals of therapy. Patients with very mild symptoms that do not interfere with activities of daily living can be observed for deterioration without treatment. In this case, the documentation submitted for review does not provide the patients degree of pain and disability. In addition, an EMG in isolation and a history of stable symptoms for 20 years do not support a diagnosis of CIDP. Even with a diagnosis of CIDP, the use of IVIG is based on clinical symptoms. Given the lack of clinical data to support a diagnosis of CIDP, the request for IVIG is not medically necessary. All told, the request for Privigen IVIG has not been established as 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 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.