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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an epidural steroid injection and an epidurogram for treatment her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  In this patients case, the requested epidural steroid injection is medically indicated.  The medical records document spinal radicular pain.  In this case, the patient had the epidural steroid injection previously and the provider documented a positive response from that injection.  However, there is a lack of support for the requested epidurogram in this patients case.  The patients MRI scan previously was negative for any neural compromise and the epidural steroid injection done subsequently already included an epidurogram.  There is no rationale supporting why an epidurogram would need to be repeated as the patient has a return of symptoms and had previously responded to the epidural steroid injection.  All told, the requested epidural steroid injection is medically necessary for the treatment of this patient.  However, the records fail to demonstrate the medical necessity of the requested epidurogram.  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 physical medicine and rehabilitation 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 Enbrel for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The Health Plan appropriately requires a Psoriasis Area Severity Index (PASI) score of greater than 10 to indicate the presence of moderate to severe psoriasis.  This information was not contained within the medical record.  Therefore, the requested medication Enbrel is not medically indicated 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 dermatology 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 continuous glucose monitor (CGM) and equipment for treatment of his type 2 diabetes (insulin dependent).   Findings:  The physician reviewer found that the American Association of Clinical Endocrinologist guidelines recommend CGM in type 1 and type 2 diabetes patients. The guidelines state, `Meaningful monitoring in patients with [Type 2 Diabetes Mellitus] T2DM should also be individualized depending on the risk of hypoglycemia estimated based on prior history, presence of hypoglycemia unawareness, and the nature of the current therapy (e.g., whether the patient is receiving medications with relatively high hypoglycemia risk, such as insulin, sulfonylureas, or glinides).  The guidelines further state, In T2DM as in T1DM, CGM can be useful in patients with unappreciated hyperglycemia, as well as in patients who are at high risk for hypoglycemia, those who have hypoglycemia unawareness, and those using intensive insulin therapy. Although this patient has a diagnosis of type 2 diabetes, his symptoms need to be managed in the same way that a patient with type 1 diabetes should be managed. As such, the patient should have access to the same tools as a patient with type 1 diabetes (i.e., CGM). The records demonstrate the patient is compliant with therapy and wants to be under better control with CGM.  In sum, CGM is a diabetes self-management tool that is more appropriate than standard management with fingerstick 4 times a day in this specific patient with diabetes type 2. Monitoring with CGM will allow the patient to make adjustments to therapy with avoidance of hypoglycemia. As such, the requested CGM and equipment is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested equipment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni 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 1 regardless of fibrosis stage. The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a pre-existing medical condition, which can be exacerbated by ribavirin. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to self or others.  Her physical disorder was well-controlled, and she was medically stable. She was compliant with her medication regimen. She was actively engaged in all aspects of the treatment program and made progress towards reducing the obsessive-compulsive disorder behavior. The patient could have been treated at a lower level of care, such as partial hospitalization program, without evidence presented that this would lead to decompensation.  She did not require 24-hour supervision at the residential level of care.  All told, residential treatment center services 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 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 acupuncture for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Although there is literature supporting an acupuncture trial for symptom reduction and function improvement for chronic lower back pain, no evidence of sustained, significant, objective functional improvement obtained with previous acupuncture was provided to support the necessity of any additional acupuncture.  Based on the records reviewed, the patient is not presenting a flare-up of the condition, or a re-injury. The use of acupuncture for maintenance, prophylactic or custodial care is not supported by peer-reviewed literature.  All told, the requested acupuncture 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 oriental 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: The parent of an enrollee has requested intensive outpatient psychiatric (IOP) level of service for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the review of the submitted documentation demonstrates the medical necessity of IOP services. The patient requires IOP to prevent an exacerbation of symptoms. A letter from the patients therapist demonstrates that the patient regressed and relapsed when treatment was not continued at the IOP level. As the patients provider indicates, the patient needs the structure of an intensive outpatient program as he is not able to comply with treatment recommendations at home. Additionally, the patients family also requires the structure of IOP level of care to maintain compliance with instructions and provide adequate support to the patient. All told, the medical necessity of the IOP level of care has been established in this case.  Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the requested therapy is medically necessary and is considered the standard of care for the treatment of patients with HCV genotype 1. Harvoni is expected to be beneficial for this patient by potentially curing his HCV infection and preventing further damage to his liver. It is also noted that treatment with anti-viral drugs such as Harvoni halts the progression of the disease process and development of cirrhosis, long-term and its potential complications including liver failure, liver cancer and death. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of sustained virologic control (SVR). Therefore, as per the American Association for the Study of Liver Diseases (AASLD) guidelines, the patient should be approved for Harvoni for 12 weeks to prevent further development and progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term. Delaying treatment could result in further progression of fibrosis, development of cirrhosis, future risk of hepatic decompensation or hepatocellular carcinoma. For these reasons, the requested course of Harvoni is supported as 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Tobii I-15 communication device including accessories for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that for people living with damage to their corticospinal and corticobulbar tracts, or spinal muscular atrophy, the use of assistive technology such as eye tracking, has been of significant benefit.  As a result of this technology, the person with no ability to create voluntary speech can become fluent and communicate again.  The programs that assist artificial generation of speech are sophisticated enough to convey the information conveyed in normal speech, including accurate representation of phonemes and diphones as well as prosody.  This represents the standard of medical care for this patient.  All told, the requested Tobii I-15 communication device including accessories is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 neurology with special qualification in child 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested Orencia for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Orencia is not a standard treatment for lupus nephritis and is not generally utilized unless there is refractory disease.  In this case, the patient has refractory disease and requires a medication that is off-label. Given that the patient has not responded to steroids, CellCept and Cytoxan there are limited options in decreased nephritis damage and the possibility of dialysis secondary to renal failure. In addition, there is literature supporting the safety of Orencia in the treatment of lupus with limited data on efficacy. Based on the clinical documentation submitted for review, the requested medication is medically necessary for treatment of the patients medical condition.  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 physician reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a repeat or second bariatric surgery for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records do not document any obvious complication of her prior gastric bypass that requires surgical intervention to treat.  There is no documentation of any anatomic complications of the prior gastric bypass.  Additionally, the records do not document ongoing dietary or behavioral follow-up since her gastric bypass.  There is a lack of support for the requested services in this clinical setting.  All told, the requested repeat or second bariatric surgery is not medically necessary 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 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: The parent of an enrollee has requested residential behavioral health services for treatment of the enrollees behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not a threat to herself or others and there was no evidence to suggest that returning to the community would lead to decompensation or deterioration. She had improved and no longer required 24-hour supervision.  During the dates of service at issue, she could have been safely treated at a lower level of care.  All told, residential behavioral health services 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 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 inpatient mental health services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the medical records submitted for review do not support the medical necessity of an inpatient level of care. The patient was calm and cooperative.  She was not suicidal or homicidal. Her medications were well tolerated and no changes were being made to the pharmacologic regimen. The record does not demonstrate the presence of an acute psychiatric syndrome or medical crisis. Thus, the requested inpatient mental health services were not medically necessary.  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 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 magnetic resonance imaging (MRI) of the thoracic spine for the evaluation of her medical condition. There is sufficient support for the requested services in this clinical setting.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, MRI is the most appropriate imaging modality.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities such as fractures, malalignments, and congenital anomalies.  However, plain x-rays are not likely to be beneficial for evaluating patients for a cause for radiculopathy.  In this case, the patient is apparently being considered for surgery. The fact that the patient is developing a radiculopathy and possible nerve compromise is further indication for more intensive evaluation.  All told, the requested MRI of the thoracic spine is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are 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.