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

Nature of Statutory Criteria/Case Summary: An enrollee has enrollee has requested authorization and coverage of Harvoni 90-400 mg tablets. Findings:  The physician reviewer found that 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, and advanced fibrosis is not required for treatment. Per guidelines, treatment naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials. Guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 90-400 mg tablets 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 authorization and coverage for physical therapy performed by a physical therapist capable of treating several complicated orthopedic issues in every session without the use of assistants twice a week.  The submitted documentation fails to demonstrate the medical necessity of the requested services. The records do not include physical therapy prescriptions documenting the recommended exercises, therapy modalities and goals. Per the records, the patient underwent physical therapy from January 2018 through March 2018, which has primarily consisted of manual therapy and ultrasound. There have been various complaints and minor injuries during this period. The duration that she has been undergoing this therapy before January 2018 is not documented or discussed.There is a lack of proven health or functional benefit of manual therapy such as myofascial release and ultrasound provided on a long-term basis. There is no proven marginal benefit with respect to palliation of these interventions over self-applied topical thermal modalities and independently performed soft tissue work, such as using a foam roller. There are no documented exercises that the patient has been performing in the formal therapy setting that could not be performed independently or substituted with independent exercise. The focus of treatment in the setting of chronic musculoskeletal spine and other body region pains should be patient education, self-care, common analgesics, independent exercise and remaining active. The benefit of prolonged formal therapy services is not established in the medical literature for these types of conditions.With respect to frozen shoulder, the clinical consensus regarding treatment of adhesive capsulitis of the shoulder has been to address etiological factors, if identifiable, and to start a gentle range of motion program that progresses over time.  The range of motion program can be started in a formal setting by physical therapists, but should be transitioned to an independent program over time.  Importantly, frequent range of motion exercise in the home setting has been shown to play a larger role in effectuating positive outcomes than the frequency of joint mobilization in a formal therapy setting. Therefore, the requested physical therapy performed by a physical therapist capable of treating several complicated orthopedic issues in every session without the use of assistants twice a week 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 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 authorization and coverage for fertility preservation (sperm extraction and storage). The records provided for review document that this patient has prostate cancer and is planning to undergo radical prostatectomy. The procedure will affect the ability to have children naturally but it does not affect his ability to produce sperms. The viable sperms can be harvested from the testicle/epididymis in the future if needed for fertility. Sperm banking would not be considered medically necessary in this case as it is not clinically indicated for management of patients prostate cancer and is not considered a generally accepted standard of care before radical prostatectomy. 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 urology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Findings:  The physician reviewer found that a female enrollee has requested reimbursement for the breast magnetic resonance imaging (MRI). Current guidelines in high risk women have just been released, and reiterated the rationale and need for aggressive breast cancer screening in high risk women, which includes breast MRI. However, this patient does not meet the described criteria. Studies demonstrate a low yield in the detection of breast cancer in a patient with a palpable abnormality in the setting of a negative mammogram and ultrasound. Most commonly, clinical follow-up is recommended, and biopsy of the palpable finding, if suspicion of breast cancer exists on a clinical basis. For these reasons, the breast MRI was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.One reviewer found that the breast MRI was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two of the three reviewers determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  One reviewer is board certified in diagnostic radiology and is actively practicing. One Reviewer is board certified in diagnostic radiology and is actively practicing.  One Reviewer is board certified in diagnostic radiology and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for laparoscopic LINX procedure. Findings:  The physician reviewer found that the LINX reflux management system has been U.S. Food and Drug Administration approved for patients with gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux. It is important to conduct appropriate patient selection before anti-reflux procedures. Pertinent to this patients case, the pathophysiology of reflux induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes.  The patient has acid reflux as based on pH recording. However, there is neither documentation that the patient is aspirating nor documentation to indicate that she is medically refractory to acid blocker drugs to warrant LINX implantation or other antireflux surgeries at this time. As such, the submitted record has not demonstrated the superior efficacy of the laparoscopic LINX procedure over available methods of treating this patients medical condition. Final Result: Two of the three reviewers determined the requested procedure is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for photodynamic therapy (CPT 96567 and J7308) provided on 12/19/17. The Health Plan has denied this request indicating that the services at issue were considered investigational for treatment of the enrollees actinic keratosis.Findings:  PDT is an effective therapy for AK that consists of topical application of a photosensitizer followed by exposure of the treatment area to a visible wavelength light source.  It is a U.S. Food and Drug Administration (FDA) approved therapy for AK of the scalp and face. The patient in this case has tried and failed several other standard therapies and so it was medically appropriate to use PDT for treatment of his skin pre-cancers. Multiple trials and meta-analyses have compared PDT with other therapies for AK. One meta-analysis of four randomized trials (641 participants with 2170 AKs) comparing PDT with cryotherapy found that PDT had a 14% greater likelihood of achieving complete lesion clearance at three months than cryotherapy (Patel et al). The appropriate treatment is generally chosen based on the number of lesions present and the efficacy of the treatment.  While destructive therapy with liquid nitrogen is standard, the FDA has approved five therapies for the treatment of actinic keratoses. These are topical 5-fluorouracil (5-FU), 5% and 3.75% imiquimod cream, topical diclofenac gel, ingenol mebutate, and PDT with topical delta-aminolevulinic acid. The provider noted failure with multiple standard therapies. All told, PDT (CPT 96567 and J7308) provided on 12/19/17 was likely to have been a superior treatment option for treating this patients AK than the available standard therapies. Final Result: All three reviewers determined the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications:  All three reviewers are board certified in dermotology 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 reimbursement for residential substance abuse treatment. The submitted documentation supports the medical necessity of the services at issue. In this case, the patients alcohol use was impairing her daily routine and contributing to significant impairment across multiple domains of functionality. Her drinking was straining her relationships. Her excessive consumption resulted in blackouts, falls, tremors and medical issues, such as transaminitis and hypertension. Further, she had co-occurring depressive illness and a history of benzodiazepine abuse. Finally, despite completion of an intensive outpatient treatment program during the episode of illness, the patient was unable to maintain sobriety in her environment. Based on the records, the patient had not consolidated the treatment gains necessary to succeed in the outpatient setting. The services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards and facilitated transition to a less restrictive setting.  Additionally, the services were reasonably expected to improve her condition and prevent a more serious episode of illness. In sum, residential substance abuse treatment was medically necessary for the treatment of this patient. 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: An enrollee has requested authorization and coverage for eye surgery (orbitotomy with removal of a mass in the orbit). The submitted documentation supports the medical necessity of the requested services. Physical examination demonstrated orbital fat herniation which was causing malposition of the conjunctiva and eyelids at the lateral commissure.  The patients tearing and vision loss symptoms are likely caused by the malformation. The standard of care in this clinical setting is to excise or debulk the mass for better lid apposition and improved functioning. Therefore, the requested eye surgery (orbitotomy with removal of a mass in the orbit) is medically necessary 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 ophthalmology 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 authorization and coverage for percutaneous tibial nerve stimulation (PTNS) services. The procedure for PTNS consists of the insertion of a needle above the medial malleolus into the posterior tibial nerve followed by the application of low-voltage electrical stimulation that produces sensory and motor responses. There is evidence in the peer-reviewed medical literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of PTNS in patients with urinary urgency and frequency. However, most trials have a small number of patients with short-term follow-up. For this reason, the role of PTNS in patients with overactive bladder remains unknown. Furthermore, this patients records do not include an urodynamic study to help determine whether the patients overactive bladder is secondary to bladder outlet obstruction from benign prostatic hyperplasia (BPH). Given the lack of support in the clinical studies and available guidelines, the requested PTNS services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Findings:  Three physician reviewers found the requested PTNS services are 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 PTNS services are 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 urology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the sTMS Mini Device for in home use. Findings:  The physician reviewer found that there is sufficient support for the requested device in this clinical setting. The efficacy of single-pulse transcranial magnetic stimulation was demonstrated in a sham-controlled trial by Lipton and colleagues which included 201 adults with episodic migraine with aura. The analysis was based upon 164 patients who treated at least one attack of migraine during the aura phase. The authors noted there were no serious adverse events related to use of the device. Per the medical evidence, transcranial magnetic stimulation should not be used to treat migraine for patients who have epilepsy, since there is theoretical concern that this treatment could trigger seizures. In this patients case, he has a history of chronic migraine. There is no evidence that the patient has a personal history or family history of seizures. Per the records, he has failed first-line migraine therapy. Therefore, the requested sTMS Mini Device for in home use is likely to be superior over other available treatment options.  Final Result: The reviewers determined that the requested device 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: Physician 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for residential treatment center 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 patient presented to the RTC acutely intoxicated. Under Dimension 1, the patients score is a 3, which correlates to acute intoxication and/or withdrawal potential. He has relapsed on cocaine and methamphetamine. The client experienced withdrawal symptoms of runny nose, paranoia, anxiety, depression, night sweats, and emotional instability. The symptoms were considered manageable and did not require intensive inpatient treatment. The patient has a history of seven overdoses with combining heroin and cocaine. Under Dimension 2, which correlates to biomedical conditions and complications, the patients score is a 0. The patient did not have any biomedical conditions or complications. Dimension 3 measures emotional, behavioral or cognitive conditions or complications medical/addictive/psychiatric co-morbidities. The patients score is a 3. The patient has severe emotional and behavioral symptomatology. The patient was impulsive, and the patients longest time of being sober outside a treatment setting was 2.5 months. Dimension 4, correlates with readiness to change. The patients score is a 2. The patient agreed to come into treatment. He reported that he wanted to remain sober to avoid homelessness. However, he frequently would miss therapy sessions and group sessions. He had a low readiness to change and was passively involved in treatment. Under Dimension 5, which correlates to relapse, continued use or continued problem potential, the patients score is a 3. The patient had poor coping skills and was a high relapse risk. Dimension 6, recovery/living environment is scored a 3. The patient was homeless and did not have a supportive environment. The patients mother was involved in the finances, but it appeared that the patient was not welcome to live with her. The patient met the medical necessity criteria to be treated in an RTC setting. The patient was homeless, had very little support, had a long history of relapsing without a structured setting and was impulsive. Therefore, RTC level of care was medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for skilled nursing facility (SNF) care. The documentation does not support that the SNF care provided as medically necessary for treatment of this patients medical condition. The documentation does not reveal complex wound care, enteral feeds, ventilator dependence or other daily skilled nursing needs. The patient did not require skilled nursing services to prevent a deterioration in condition or skilled nursing services to establish a safe and effective maintenance program beginning on 3/13/18. The documentation does not reveal that the patient required daily skilled therapy services, daily skilled nursing services, or inpatient skilled daily therapy to prevent deterioration with mobility and/or activities of daily living, or establish a safe maintenance program. As of 3/13/18, the patients needs can be met at a lower level of care. Thus, the SNF care was not and is not medically necessary for treatment of this patients medical condition. 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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.