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 virus.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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 medical guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. 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. The guidelines also cite data showing increased survival with earlier treatment. 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 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 (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  The physician reviewer found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor.  Based on the documentation submitted for review and peer reviewed literature, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: The reviewer 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: The reviewer is board certified in diagnostic radiology 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 Harvoni for 12 weeks 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 guidelines, patients with liver transplant are considered high priority for treatment. Viekira Pak is not recommended by AASLD guidelines after liver transplant. The guidelines recommend Harvoni monotherapy (for 24 weeks) only in treatment-naive ribavirin-ineligible patients with genotype 1. The only AASLD recommendation for ribavirin-eligible genotype 1 liver transplant patients is Harvoni with weight-based ribavirin for 12 weeks. This is based on the SOLAR-1 trial of Harvoni in post-transplant recipients, which demonstrated 96% sustained virologic response in this population, and a low rate of discontinuation due to ribavirin side effects (Charlton, et al). In this case, the patient does not have anemia or sufficient renal failure that would preclude ribavirin use. In addition, the medical records do not mention the addition of ribavirin to the Harvoni regimen. Per AASLD/IDSA guidelines, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the presence of dense breast tissue is an indication for tomosynthesis. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. Therefore,  breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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 physicians are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical conditions 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.  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 guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. 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 physician 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 an overnight hospital stay 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 patients clinical picture was consistent with a transient ischemic attack, and his neurological symptoms had resolved prior to admission.  His comorbid conditions did not require complex management.  The services provided in this case were consistent with observation care.  Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short-term treatment, assessment, and reassessment before a decision can be made regarding whether patients will require further treatment as hospital inpatients or if they are able to be discharged from the hospital.  In this case, the services provided were telemetry monitoring and reassessments to ensure that there was no recurrence of neurologic symptoms while the patient underwent diagnostic testing.  This patient could have appropriately been treated at a lower level of care.  All told, overnight hospital stay 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 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: 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 the proposed treatment regimen of Harvoni for eight weeks is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score.  The fixed-dose combination ledipasvir-sofosbuvir (Harvoni) was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in adults. The fixed dose combination ledipasvir-sofosbuvir is FDA-approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. The treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. According to the literature, treatment duration of eight weeks can be considered in treatment-naive patients, without cirrhosis, who have a baseline HCV RNA level less than 6 million IU/mL based on post-hoc analysis of the clinical data from the ION-3 trial (Kowdley et al). Therefore, the patient should be approved for Harvoni to prevent further development and progression of fibrosis due to ongoing HCV infection and to avoid potential complications of advanced liver disease.  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 Provigil for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has fatigue related to multiple sclerosis.  She has been treated with Provigil, with reported benefit.  There is evidence in the medical literature that Provigil can be of benefit in the off-label treatment of fatigue in conditions such as multiple sclerosis.  The alternative treatments have greater side effects and abuse potential.  In this patients case, Provigil is medically indicated.  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 neurology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested ambulance transport services on an emergent basis.  Findings: The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention and would not have reasonably believed that the condition required ambulance transport services on the date in question. In this case, the patient called 911 due to an abdominal pain which was getting worse. The patient was not in severe distress and her presenting signs and symptoms were not acute symptoms of sufficient severity. Thus, her symptoms were not of sufficient severity that a prudent layperson would reasonably believe the absence of immediate medical attention would place his health in serious jeopardy or result in serious impairment to bodily functions or serious dysfunction of any bodily organ or part. All told, based upon the documentation provided for review, the patients symptoms did not meet prudent layperson criteria for immediate medical attention or ambulance transport. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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. Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the medical guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. 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. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni is medically necessary for treatment of the patients hepatitis C virus. 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 vestibular autorotation testing (VAT) for evaluation of his medical condition. Findings:  Three physician reviewers found that vestibular rotation testing is a high frequency, active head rotation test used to subjectively evaluate the vestibular-ocular reflex and its function. Patients wear a lightweight head-strap with a velocity sensor on the back. The patients follow instructions to shake their head, first side-to-side, and then up-and-down. Conventional electro-olfactogram electrodes placed around the eyes measure eye movements. Although some published studies have suggested that the VAT may be useful in evaluating patients with vestibular disorders/diseases, there are few studies that examined the sensitivity and specificity of the VAT in evaluating patients with suspected vestibular abnormalities. Furthermore, there is a lack of data supporting the value of the VAT in the management of patients with vestibular disorders/diseases. There are other accepted tests of the vestibular system that are available. For the reasons provided, the requested services are not likely to be more beneficial for evaluation 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 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 physical medicine and rehabilitation with a sub-specialty certification in pain management and is actively practicing. One reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing.  One reviewer is board certified in physical medicine and rehabilitation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing (Foundation One) and genetic testing (Guardant Molecular Profiling) for evaluation of her medical condition.  Findings:  Two physician reviewers found that in this case, the patients tumor is rare and so the medical literature has small case series describing chemotherapy responsiveness, resistance, and in one case a good result from high dose chemotherapy followed by autologous stem cell transplant. As such, Foundation One testing was indicated and likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. However, Guardant Molecular Profiling is not the standard of care in this clinical setting. As such, the Guardant Molecular Profiling 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 that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:   One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified 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 Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that the requested treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. 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. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed regimen of Harvoni is consistent with FDA guidelines and is medically necessary to prevent further development and progression of fibrosis due to ongoing HCV infection. All told, the requested Harvoni  is medically necessary for treatment of the patients hepatitis C virus.  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.