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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Actemra for the treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Bortezomib would be the next agent to attempt to eliminate donor specific antibodies.  Per the current medical evidence, there is a lack of support for Actemra in treating antibody mediated rejection.  The medical records do not support the requested medication in this clinical setting.  All told, Actemra 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 internal medicine with sub-specialty certification in nephrology 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 Viekira Pak for treatment of her 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), the recommended regimen for treatment-naive patients with HCV genotype 1a infection include daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir and weight-based ribavirin for 12 weeks as a Class I, Level A rating.  Paritaprevir/ritonavir/ombitasvir plus dasabuvir and weight-based ribavirin was approved by the U.S. Food and Drug Administration (FDA) for the treatment of HCV genotype 1a infection in treatment-naive patients based on registration trials. Based on the support provided, the request for Viekira Pak is medically necessary for treatment of the patients HCV, genotype 1a.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza and Sovaldi for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks, regardless of interferon eligibility. This is based on the ALLY-3 study, which showed a cure rate of 97%. In this case, the patient is ineligible for interferon-based alternatives due to anxiety. In addition, the guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the use of an electromyography (EMG) machine to guide the Botox injections for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. According to the documentation submitted for review, the patient presents with cervical dystonia and has been treated with Botox injections. The patient reports a significant relief when Botox injections are provided with the guidance of EMG. Researchers examined whether multichannel electromyographic mapping improved outcomes in a cohort of antibody-negative onabotulinumtoxinA non-responders by more precisely identifying which muscles were involved in the dystonia. The authors reported that EMG mapping may result in improved efficacy in treatment of cervical dystonia with Botox. In sum, there is support in the literature for EMG guidance for delivery of Botox for treatment of cervical dystonia. Therefore, the request for EMG machine to guide the Botox injections is medically indicated for 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 neurology 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: An enrollee has requested Xanax for treatment of her behavioral health condition. Findings:  The physician reviewer found that in this clinical setting, treatment with Xanax is medically necessary. It is appropriate for the treatment team to eventually transition this patient from Xanax to non-addictive treatments for her symptoms, and it appears that they have been somewhat successful to date; the patient had reduced her Xanax usage. Given that her dosage of Xanax is fairly low, she should be at a lowered risk of complications from Xanax such as dementia and dependence. All told, the requested medication is indicated for the treatment of the patients behavioral health 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 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.  Findings:  The physician reviewer found that based upon 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. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. This guideline recommendation is 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 . For these reasons, the request for a 12-week course of Harvoni is supported as medically necessary for treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) scan of the brain (cerebral perfusion imaging using CT) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the CT scan of the brain (cerebral perfusion imaging using CT) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this clinical setting, the CT perfusion was indicated to rule out acute stroke, given that this patient has multiple risks factors for strokes. In sum, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two 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 reviewer number one is board certified in neurology with sub-specialty certification in neuro-oncology and is actively practicing. Physician reviewer number two is board certified in radiology with sub-specialty certification in neuro-radiology and is actively practicing. Physician reviewer number three is board certified in medical oncology 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 placement of a left ventricular pacing lead add-on for treatment of his medical condition.   Findings:  Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. There is a lack of support for placement of a left ventricular pacing lead add-on in this clinical setting. The peer-reviewed literature does not support left ventricular pacing lead, unless the patient has left bundle branch block morphology and QRS duration more than 150 milliseconds. In this case, the patient has a QRS complex of less than 120 milliseconds. In addition, the patient does not have permanent atrial fibrillation or a near 100% ventricular pacing need. Therefore, the placement of the left ventricular pacing lead add-on is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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: 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 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. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL, ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lab testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the lab test was not likely to be more effective for this patient than other available options. Per the American Joint Committee on Cancer (AJCC), the presence of circulating tumor cells in the blood does not define metastasis. For metastatic disease, the enumeration of circulating tumor cells at the time of diagnosis of metastasis has been shown to strongly correlate with survival, but neither the presence nor the number of circulating tumor cells will change classification.  Researchers showed that for patients with persistent elevation of circulating tumor cells after 21 days of chemotherapy, early switching to an alternative regimen did not prolong survival. Thus, the lab testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were 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:  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested extracorporeal shock wave therapy for the treatment of her medical condition.  Findings:  Two physician reviewers found that the medical evidence supports the requested services in this clinical setting.  This patient has Kohlers disease which is a condition affecting the vascularity to the navicular bones that has the potential of altering the shape and joint surfacing of an important mid-foot joint.  In this patients case, the records document failed conservative therapy.  In sum, the requested extracorporeal shock wave therapy is likely to be more efficacious than other treatment options.   Final Result: Two reviewers determined that the requested services are 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 orthopedic surgery 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 skilled nursing facility services for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient has been in the inpatient rehabilitation setting for a prolonged period of time without making significant functional progress.  She had essentially plateaued with respect to function at requiring maximum to total assistance for most of her self-care and mobility.  Going forward, the patient would not be expected to make significant functional progress in a reasonably predictable and timely fashion.  The medical literature does not support the necessity of this intervention in the absence of demonstrated and expected functional progress.  All told, skilled nursing facility 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intensive outpatient services for treatment of his behavioral health condition. Findings:  The physician reviewer found that intensive outpatient services were initially medically necessary for treatment of the patients medical condition, but not thereafter. Given the history provided,  the likelihood of substance use would have worsened without the structure of the intensive outpatient setting to provide support and feedback from peers and therapists. However, subsequently he was described as insightful and knowledgeable about recovery. He was medically and psychiatrically stable and was motivated for recovery. As such, intensive outpatient services level of care was initially medically necessary, after which he could have been treated at outpatient level of care with a concurrent community based support of a 12-step program and a sponsor. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a positron emission tomography (PET) scan for evaluation of her medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Groheux and colleagues noted when a recurrence is depicted or a patient is suspected of having a recurrence by using conventional imaging, PET/CT is useful to determine whether this recurrence is isolated or not, and such a determination may have a potential effect on the patients treatment.  There is sufficient support in the literature for the use of PET to follow-up in this case.  In sum, the PET scan performed was likely to have been of greater benefit than other options for evaluating this patient. Final Result: Two 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.