Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Foundation One genetic testing for evaluation of her medical condition. Findings:  Two physician reviewers found that next generation sequencing, such as Foundation One, is considered a standard of care in this clinical setting.  The testing performed may assist providers in making therapy decisions, and many institutions require testing before consultation to determine available clinical trials.  All told, Foundation One genetic testing was likely to have been superior over other methods of evaluating this patient. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an inpatient hospital stay for treatment of his medical condition.  Findings:  The physician reviewer found that this patient was treated for acute pancreatitis, hypertension and diabetes.  He was not tolerating an oral diet.  He continued to require intravenous fluids and had an increasing white blood cell count which is concerning for untreated infection.  Subsequently, he was voiding and tolerating an oral diet.  His vital signs were stable and afebrile, and his laboratory test results were normalizing.  The patient was using oral analgesic medications for chronic pain issues.  At this point, he could have been safely transferred to a lower level of care.  All told, inpatient hospital stay was medically necessary initially, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient is requesting Otezla, an oral phosphodiesterase inhibitor used for the treatment of psoriasis. She was treated with methotrexate for several years. It was recommended that she switch therapies given the risks of long-term methotrexate therapy. However, in this case there is no medical documentation of failure or intolerance to Enbrel or Humira. There is no documentation of contraindications to these therapies outside of age and risk of infection. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the wearable cardiac defibrillator (Zoll LifeVest) for treatment of her medical condition.  Findings:  Three physician reviewers found that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The peer reviewed literature does not support a benefit or improved outcome as compared to standard medical therapy with deployment of the LifeVest in this clinical setting. All told, the wearable cardiac defibrillator (Zoll LifeVest) was not likely to be more beneficial for treatment of the patients medical condition than other standard therapies. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential behavioral health services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The records failed to demonstrate that less restrictive interventions targeting his substance use during the episode of illness had either been unsuccessful or would have been inappropriate.  It appears that the patient was psychiatrically stable with individual and group therapy and psychotropic medication. Additionally, the medical records did not include critical documents from the treatment facility. Thus, residential treatment provided was not medically indicated for the treatment of this patient.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 intensive outpatient psychiatric treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that in this case, the patients diagnoses has caused significant intrapsychic distress and functional impairment. As in all conditions, the least restrictive level of care is preferred, and the determination of the ideal care setting is best made by the providers most familiar with the clinical situation and treatment needs. The patients psychiatrist has recommended continued treatment at the intensive outpatient level of care, which is a setting endorsed by the American Psychiatric Association for the treatment of OCD. Treatment at this time cannot reasonably be conducted in a less restrictive setting while less intensive treatment would result in inadequate care. The intensive outpatient setting is reasonably expected to both improve her condition and prevent a more serious episode of illness. Further, the intensive outpatient setting represents a safe and appropriate placement consistent with good medical practice. As such, the services at issue were and are medically necessary for treatment of the patients medical condition. 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 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 acute inpatient mental health treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that inpatient psychiatric care is aimed at decompressing the acute exacerbations of episodic serious mental illness. In this case, the patient presents with medical issues and psychosis cast upon an autistic baseline. The American Psychiatric Association articulates this process stating The psychiatrist should determine the least restrictive setting for treatment that will be most likely not only to address the patients safety, but also to promote improvement in the patient's condition. The determination of an appropriate setting for treatment should include consideration of the patient's symptom severity, co-occurring psychiatric or general medical conditions, available support system, and level of functioning. In this particular case, psychiatric hospitalization was initially indicated and discharge during this time would have been premature. Based on the illness severity, treatment at this time could not have been reasonably conducted in a less restrictive setting. The inpatient team was relying on a medication protocol in a specialty setting yet the illness burden that prompted the admission had not yet been adequately controlled. This type of protracted response is not uncommon as treatment with a medication like she was prescribed often results in initial positivism due to its sedating effects but the more enduring antipsychotic effects can take significantly longer to achieve. As active treatment continued, including family involvement and the administration of prescribed medications, the patient began to improve. She had a family meeting scheduled which would have been a reasonable opportunity to progress with transition to a less restrictive treatment setting. Although the patient will require long-term specialty services provided by behavioral health care professionals, the acute psychiatric syndrome that prompted the admission had resolved. Thus, based on the documentation provided, the initial services at issue were medically necessary but not thereafter. Final Result: The reviewer determined that a portion of the services at issue were 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 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 skilled nursing facility services and physical therapy service while receiving skilled nursing facility services for treatment of her medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for 24-hour skilled nursing facility care has not been established. In this case, the patient has dementia with baseline impairment of functional mobility. She has shown improvement in self-care and functional mobility from her nadir while in skilled nursing facility. Her improvement has plateaued and she is likely at her new baseline level of function. Moreover, a provider has not recommended additional inpatient skilled nursing facility rehabilitation. The records do not demonstrate a need for skilled nursing facility level physical and occupational therapy. As such, the request for skilled nursing facility services and physical therapy services while receiving skilled nursing facility services has not been established as medically necessary. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested buprenorphine for treatment of his medical condition.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for buprenorphine has not been established. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. According to the documentation submitted for review, the patient is not participating in a comprehensive pain management program. In addition, researchers reported that opioid agonist-antagonist have been approved for opioid addiction. Doctors are often hesitant to prescribe agonist-antagonist and partial agonist to opioid tolerant patients, fearing that these drugs may precipitate withdrawal.  Researchers also reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for buprenorphine is not medically necessary. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested in-home physical therapy for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that physical therapy is a mainstay of treatment for cerebral palsy.  Its focus on function and movement maximizes the patients potential.  In addition, physical therapy teaches patients ways to optimize their independence and self-help skills.  Physical therapy is part of a multifaceted approach, including medications and surgery.  Duration and intensity of therapy appear to be more important than the specific methodology used; often, use of multiple methods is necessary to provide the most effective treatment.  For those who are severely affected, comfort and ease of care are often the goals of therapy.  However, for adolescents, therapy should be geared toward establishing functional mobility and independence.  This patient requires physical therapy for prevention of contractures and facilitation of functional mobility and interaction with her environment.  Because of a preexisting medical condition, she is unable to participate in activities outside of the home without risk of infection; therapy outside of the home would provide unnecessary exposure and risk.  All told, the requested in-home physical therapy is medically indicated for the treatment of this patient.  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 pediatrics with sub-specialty certification in pediatric critical care 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 Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that Harvoni is medically necessary for treatment of the patients medical condition. According to the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In this case, the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 1. Moreover, the requested medication prevents further damage of the liver and progression of the disease process. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage.  All told, Sovaldi and ribavirin are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Due to the tomographic qualities of this technique, radiologists are often able to subtract out underlying dense glandular tissue from architectural distortion thereby decreasing callbacks and increasing detection of small cancers.  This advantage is particularly seen in patients with heterogeneously or very dense breast tissue.  The addition of the technique has gained worldwide favor among radiologists for the advantages described above.  Thus, the addition of three-dimensional breast tomosynthesis to the usual two-dimensional screening mammographic images is likely of more benefit to the patient than two-dimensional mammography alone. 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 Harvoni for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that according to the guidelines, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. 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. In addition, guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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.