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 Vemlidy, 25 mg daily. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis B.Findings: Guidelines for the treatment of hepatitis B from the American Association for the Study of Liver Diseases (AASLD) recommend entecavir and tenofovir compared to alternatives for the treatment of chronic hepatitis B. In comparison with tenofovir disoproxil fumarate (Viread), the Vemlidy formulation of tenofovir is effective for treatment of hepatitis B, but is associated with lower incidence of side effects such as osteopenia and renal disease. As such, the request to switch the patient to Vemlidy to reduce the risk of tenofovir-related nephrotoxicity and loss of bone density is medically reasonable and appropriate. For these reasons, Vemlidy 25 mg daily is medically necessary for the treatment of this patients hepatitis B. 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 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: The parent of an enrollee has requested reimbursement for behavioral health residential treatment care (RTC) services.  The Health Plan has denied this request indicating that the services at issue were not medically necessary for treatment of the enrollees behavioral health condition.Findings: The submitted documentation fails to demonstrate the medical necessity of the services at issue in this clinical setting. The patient reported that he did not have suicidal or homicidal thoughts. The provided records did not indicate that the patient had history of any suicide attempts. The patient had not attended a partial hospitalization program (PHP) or an intensive outpatient program prior to his admission to the RTC. The patients parents were supportive of the patient. The patient participated in treatment. The patient did not have psychotic symptoms. The patient did not have medical problems, which would require 24 hour supervision.  It is standard of care to treat all patients in the least restrictive environment as possible. It does not appear that this patient required 24 hour supervision. The patient did require treatment, but based on the records, this patient could have been treated at a lower level of care in a PHP setting with daily psychotherapy integrated with medication management. Therefore, behavioral health residential treatment care services were not medically necessary.  Final Result: The reviewer determined that the requested name brand 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 psychiatry with expertise 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 authorization and coverage for Synvisc One injection to the right knee. There is adequate evidence that intraarticular hyaluronic acid injections reduce pain and increase function in knee osteoarthritis, and the benefits are long-lasting as compared with intraarticular corticosteroids. A systematic review of overlapping meta-analyses comparing viscosupplementation with other non-operative treatment modalities for knee osteoarthritis. It was reported that the current highest level of evidence suggests that intraarticular hyaluronic acid is a viable option for patients with knee osteoarthritis which results in improvements in knee pain and function that can persist for up to 26 weeks. Viscosupplementation has a good safety profile, and its use should be considered in patients with knee osteoarthritis. All told, the requested Synvisc One injections to the right knee is supported as medically necessary for treatment of this patients knee osteoarthritis. Final Result: The reviewer determined that the requested services 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 orthopedic 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for coronary calcium computed tomography (CT). Findings:  Two of the three physician reviewers found there is support for the services at issue in this clinical setting. This patient has some risk factors for coronary artery disease. The records documented symptoms of new onset chest discomfort which could be related to coronary disease despite her relatively lower, but not insignificant, risk profile. There is published data indicating that this modality can provide excellent negative predictive value to rule out coronary artery disease in lower risk, but symptomatic, individuals. All told, coronary calcium CT provided was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for Nutropin AQ Nuspin pen injector. The patients height is not more than two standard deviations below the mean for age and gender. In addition, no evidence was provided of height fall-off. Results of laboratory testing ruling out other causes of short stature were not provided for review. Information on the patients insulin like growth factor-1 (IGF-1) and insulin like growth factor binding protein-3 (IGFBP-3) levels are not provided. The patients bone age is normal for his age. Applying the American Association of Clinical Endocrinologists and Lawson Wilkins Pediatric Endocrinology Society Drug and Therapeutics Committee guidelines, the patient does not meet standard criteria for GH deficiency. Thus, the requested Nutropin AQ Nuspin pen injector is not medically necessary for treatment of this 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 pediatrics with sub-specialty certification in pediatric 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 authorization and coverage of Mavyret 100-40 mg tablets. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees hepatitis C virus, genotype 1a.According to the recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients be treated with Mavyret three tablets daily for eight weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg tablets to treat the patients hepatitis C is supported as medically necessary. 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: A patient has requested authorization and coverage for Orencia Clickjet 125 mg/mL. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the patients seropositive rheumatoid arthritis. The submitted documentation does not support the medical necessity of the requested medication. This patient has been diagnosed with seropositive RA. The records do not indicate the severity. The U.S. Food and Drug Administration (FDA) has approved Orencia for the treatment of patients with moderately to severely active RA, who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors. The current guidelines recommend tumor necrosis factor inhibitors as the first line therapy for active RA. The American College of Rheumatology guidelines recommend methotrexate with or without tumor necrosis factor inhibitors as the next treatment in those who have failed methotrexate alone. Based on the medical records provided, it is unclear that the patient has moderate to severe active RA, as previous records and examinations were not provided. The patients previous treatment has included nonsteroidal anti-inflammatory drugs and Tylenol. Given the patients use of alcohol, methotrexate would be relatively contraindicated. However, travel is not a contraindication to tumor necrosis factor inhibitors use. The medical records fail to demonstrate evidence of the patients failure, intolerance, or contraindications to these medications. As such, Orencia Clickjet 125 mg/mL is not medically necessary for 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 internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for hip replacement surgery. The Health Plan has denied this request indicating that the requested services are not medically necessary for treatment of the enrollee who has a history of hip pain.Findings: Nationally recognized evidence based medical guidelines recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. The criteria include conservative care with exercise therapy, medications, and documented significant weight loss effort with BMI greater than 30. It was noted that surgery should be delayed a minimum of three months, preferably one year following any intra-articular corticosteroid injection due to increased risk of periprosthetic infection. Subjective findings should include limited range of motion, or nighttime joint pain, or no pain relief with conservative care. Objective findings should include over 50 years of age and a BMI less than 35 as increased BMI poses significantly elevated risks for post-operative complications. Imaging findings of osteoarthritis on standing x-rays or arthroscopy are required. A review of a total of 10,690 primary total hip arthroplasties and concluded that obesity was one of the most important modifiable patient factors in predicting periprosthetic joint injection following total hip arthroplasty. This patient reported a two year history of ongoing left hip pain with a constant grade of 5 out of 10 pain with medications. However, evidence based medical guidelines and peer-reviewed literature indicate that an elevated BMI poses significantly increased risks for post-operative complications and recommend a BMI of 35. Additionally, guidelines recommend that total hip replacement be delayed at least three months following corticosteroid injection due to the increased risk of periprosthetic infection. An orthopedic report indicated the patient underwent a left hip corticosteroid injection. While the patient has lost weight, her BMI is still significantly elevated. Accordingly, the records do not present a compelling rationale to support the medical necessity of total hip replacement in the setting of an elevated BMI and within three months of corticosteroid injection. Therefore, the requested services are not medically necessary in the treatment of the patients medical condition. 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 orthopedic 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 a consultation/office visit with a nephrologist.  The submitted documentation fails to demonstrate the medical necessity of the requested services. This patient has chronic abdominal pain. An incidental adrenal mass was discovered during CT imaging.  An adrenal incidentaloma is a mass lesion greater than 1 cm in diameter, discovered accidentally during radiologic examination. For a patient with an adrenal incidentaloma that is 2.4 cm, they should be evaluated for the possibility of malignancy and subclinical hormonal hyperfunction.  A referral to an endocrinologist is an appropriate first step to the evaluation. In this case, the documentation does not support that the patient has any underlying kidney disease or dysfunction. Thus, the requested consultation/office visit with a nephrologist 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 internal 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 authorization and coverage for peroral endoscopic myotomy (POEM). The Health Plan has denied this request indicating that the requested procedure is considered investigational for treatment of the enrollee who has been diagnosed with type II achalasia.Findings The American Gastroenterological Association best practice guideline for POEM states that, if the expertise is available, POEM should be considered as treatment option comparable with laparoscopic Heller myotomy for any of the achalasia syndromes. The American Society for Gastrointestinal Endoscopy has recently published a statement based on available evidence, stating that POEM is a potential attractive option for the treatment of achalasia that offers a minimally invasive endoscopic approach to myotomy with the potential for a durable response to therapy . In this patients case, she presents with severe symptoms not improved with proton pump inhibitor therapy. The use of POEM in this clinical setting is supported by current medical literature and guidelines.  For these reasons, POEM is likely to be of greater benefit for treatment of the patients medical condition than any available standard treatment modality.Final Result: All three reviewers determined the requested procedure 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:  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for sacroiliac (SI) joint fusion. According to the coverage criteria by the International Society for the Advancement of Spine Surgery (ISASS), the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The patient presents with significant SI joint pain and has failed to respond to at least six months of non-surgical conservative therapy. However, the patients SI joint pain has not been confirmed with at least three physical examination maneuvers that stress the SI joint and cause the patients typical pain such as distraction test, compression test, thigh thrust and FABER test. In this case, there is insufficient evidence of adequate documentation of three physical examination maneuvers demonstrating SI joint pain to warrant the procedure. Therefore, by the medical literature the patient does not meet the current ISASS criteria for a SI joint fusion.Findings:  Three physician reviewers found the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested SI joint fusion is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a minor enrollee has requested authorization and coverage for growth hormone (GH) treatment at pediatric dosage. Continued administration of GH therapy at pediatric doses is medically necessary for this patient until epiphyseal fusion or until the patients growth velocity decreases to less than two centimeters per year. After that time, the patient should be retested for adult GH deficiency. Thus, the patient meets the current criteria for continued administration of GH at pediatric doses for treatment of hypopituitarism secondary to cranial irradiation, as his epiphyses remain open and his growth velocity is greater than two centimeters per year. All told, the requested GH treatment at pediatric dosage is supported as medically necessary for treatment of this 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 reviewer is board certified in pediatrics with sub-specialty certification in pediatric 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.