Persius/hicric huggingface dataset:
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.  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. The guidelines state that patients with HIV co-infection are at high risk for complications and should be prioritized for treatment.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines also recommend Technivie/ribavirin for 12 weeks.  However, the guidelines specifically recommend against the use of Technivie/ribavirin with darunavir, which the patient takes for HIV.  All told, Harvoni is medically indicated for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiotherapy for treatment of her medical condition. Findings: Three physician reviewers found that stereotactic body radiotherapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Stereotactic body radiotherapy is generally performed when there is a single lesion which needs more curative radiotherapy.  In this case, the patient has multiple lung metastases which have persisted or recurred after chemotherapy. There is a lack of medical literature that supports stereotactic body radiotherapy for the treatment of metastatic choriocarcinoma with multiple lung metastases which are not symptomatic.  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 physician reviewers are board certified in radiation 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested anesthesia services during a colonoscopy for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient had a low American Society of Anesthesiologists (ASA) preoperative physical status classification score. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well-supported in both clinical practice and in the research given a low preoperative physical status classification score.  The current medical evidence does not support the services at issue in this clinical setting.  All told, anesthesia services provided during a colonoscopy were 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 anesthesiology 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 anesthesia services provided during an esophagogastroduodenoscopy/colonoscopy for the 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 did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, anesthesia services during an esophagogastroduodenoscopy/colonoscopy were 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing decreased survival with delayed treatment. Although AASLD/IDSA guidelines do not substantiate concerns over the interaction of Viekira Pak with abacavir/lamivudine, the patient should be considered ineligible for Viekira Pak/ribavirin due to his history of anemia with ribavirin in the past coupled with ongoing chronic kidney disease.  For these reasons, the requested course of Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nutropin for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the medical necessity of the requested medication.  Growth hormone treatment is not indicated for growth failure in association with chronic illness and will have limited efficacy in the setting of concomitant steroid administration, even at doses of steroids that are relatively low.  This patients insulin-like growth factor 1 (IGF-1) level is appropriate for a pre-pubertal/early pubertal female and is not indicative of bona fide growth hormone deficiency.  The growth velocity would be expected to pick up as puberty progresses, as long as the underlying chronic disease is well-controlled.  All told, the requested Nutropin 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested autonomic nerve and sweat testing for the evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  This patient has had a complex history suggesting a dysautonomia.  Prior test results were thought to have possibly been altered by concurrent medications, and autonomic system testing was performed.  The clarification of diagnosis in a complex case of this sort lead to changes in treatment plans regarding further medications.  All told, the autonomic nerve and sweat testing were likely to have been of greater benefit than 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 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 neurology 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 Oncotype DX Prostate Cancer Assay testing for evaluation of his medical condition.  Findings:  Two physician reviewers found that the Oncotype DX Prostate Cancer Assay is a real time polymerase chain reaction (RT-PCR) assay designed for analysis of prostate core needle biopsies. The assay measures the expression of 17 genes to calculate a GPS. The National Comprehensive Cancer Network (NCCN) guidelines in regards to Oncotype DX testing state Their clinical utility awaits evaluation by prospective, randomized clinical trials, which are unlikely to be done. The marketplace and comparative effectiveness research may be the only means for these tests and other like them to gain their proper place for better risk stratification for men with clinically localized prostate cancer. While Oncotype DX may eventually have a role in making treatment decisions for patients with prostate cancer, there is limited data on clinical outcomes to currently support its use. All told, the services at issue were 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 urology 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 Sovaldi and Ribasphere for treatment of her hepatitis C virus.   Findings:  The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment 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 addition, per AASLD/IDSA guidelines, the highest-rated `Recommended regimen for treatment-naive patients with HCV genotype 2, regardless of eligibility for IFN therapy, is daily sofosbuvir and weight-based RBV for 12 weeks. Thus, the recommended regimen for treatment-naive patients with HCV genotype 2 infection without cirrhosis is Sovaldi and Ribasphere for 12 weeks, a Class I, Level A recommendation. As such, the requested treatment is medically necessary for the treatment of the patients medical condition. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan infusions for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the medication at issue. In this case, the patient has a reported history of rheumatoid arthritis. Her treating provider indicates that that the patient has tried several medications with inadequate response, however there is a lack of clinical documentation to support this. In addition, the patient reports that rituximab helped her in the past. However, there are no records to support this as well. Moreover, there is no documentation the patient has tried and failed anti-tumor necrosis factor (TNF) agents.  Based on the clinical documentation provided, Rituxan infusions were not and are not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was not and 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 and allergy and immunology with sub-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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested neurologic music therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Researchers performed a review to assess the effects of music therapy for individuals with Autism Spectrum Disorder (ASD). The authors concluded The findings of this updated review provide evidence that music therapy may help children with ASD to improve their skills in primary outcome areas that constitute the core of the condition including social interaction, verbal communication, initiating behaviour, and social-emotional reciprocity. Music therapy may also help to enhance non-verbal communication skills within the therapy context. Furthermore, in secondary outcome areas, music therapy may contribute to increasing social adaptation skills in children with ASD and to promoting the quality of parent-child relationships. In addition, other researchers, in regards to treatments for ASD, state that the most promising therapies recommended are applied behavior analysis, parent-implemented training, melatonin supplements to improve sleep, supplements to correct deficiencies, and music therapy. Given the support in peer-reviewed literature, the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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: One reviewer is board certified in pediatrics and neurodevelopmental behavioral pediatrics and is actively practicing.  One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak for treatment of his hepatitis C virus (HCV). Findings: The physician reviewer found that per the 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 includes 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. The SAPPHIRE-I trial included 322 treatment-naive patients with genotype 1a HCV infection (Feld, et al). The SAPPHIRE-I trial reported a high sustained virologic response (SVR) rate (95.3%) with 12 weeks of paritaprevir/ritonavir/ombitasvir plus dasabuvir and ribavirin (Feld, et al). In addition, the PEARL-IV trial included 305 treatment-naive patients with genotype 1a. Based on the results of these studies, paritaprevir/ritonavir/ombitasvir plus dasabuvir (Viekira Pak) is well-supported as effective therapy for the treatment of chronic hepatitis C, genotype 1a. Accordingly, the request for Viekira Pak is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The 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 Decision DX Melanoma multivariate gene expression assay for the evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The prognosis of cutaneous melanoma has classically been determined by the staging system spelled out by Balch.  Mitotic index has also been thought to add a bit more to the prognostics. By these determinations, this patient has a very low risk of recurrence and would not be considered for adjuvant therapy.  Decision DX is the study of 31 genes in the melanoma cells.  It then classifies that particular melanoma as either Class 1 (with a 97% disease-free state at five years), or Class 2 (with a 31% disease-free rate at five years).  Per the medical literature, there is good correlation between prognosis and Decision DX classification.  However, it is not clear how Decision DX data compares to the ten-year data of the Balch determinations, and whether it can be used in clinical practice.  This is significant in this patients case, given his excellent prognosis.  All told, the Decision DX Melanoma multivariate gene expression assay was not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation 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 medical oncology 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.