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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Harvoni 90/400 mg for eight weeks.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, and advanced fibrosis is not required for treatment. 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 with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 reimbursement for the Afirma gene test. Findings:  Three physician reviewers found that the Afirma gene expression classifier test conducted was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The cytopathology of the thyroid nodule was consistent with AUS which carries a risk of malignancy of 5-15%. The American Thyroid Associations (ATA) guidelines state that for nodules with AUS/follicular lesion of undetermined significance (FLUS) cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. The ATA guidelines also recommends taking the patients history, ultrasound appearance and other clinical factors in consideration. In this case, the nodule was worrisome, given the size of the nodule and the fact that it was cold in scan. If the genetic test is suspicious, the risk of malignancy increases to 40%. However, the risk of malignancy decreases to less than 6% with benign findings by genetic testing. Final Result: Three reviewers determined that the testing 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 overturned. Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that in the peer-reviewed medical literature, colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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 overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed for evaluation of the enrollees risk for breast cancer. Findings:  2/3 of the physician reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: 2/3 of the reviewers determined that the diagnostic procedure 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 overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 reimbursement for continued inpatient psychiatric hospitalization (IP) treatment from 8/22/16 through 8/31/16. Findings:  The physician reviewer found that on 8/22/16, the patients psychosis had improved.  She was stable on antipsychotic medication. She was calm, cooperative and pleasant. She was neither agitated nor intrusive. She was not suicidal. She was sleeping nearly eight hours per night.  She was anxious about discharge, and still demonstrated findings consistent with a formal thought disorder. However, the psychiatrist considered her appropriate for discharge back to a less restrictive setting. A critical element to a successful inpatient psychiatric hospitalization is appropriate aftercare.  Although a return to a prior residence is often ideal, suitable alternatives may be clinically appropriate.  In this case, the record indicates that the illness burden which had prompted the hospitalization had improved significantly.  Although disabled by chronic mental illness and in need of a supervised setting, there was no evidence of an acute psychiatric syndrome or medical crisis as of 8/22/16.  Thus, a less restrictive treatment setting, such as a sub-acute crisis bed or short-term residential unit, would have been clinically appropriate. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A parent of an enrollee has requested authorization and coverage for spectrum sound therapy program, including the Spectrum Achieve Level One (nature music) from Advanced Brain Technologies for in-home use and pre-writing therapy program to assist with fine motor strengthening and manipulation from Handwriting without Tears for in-home use.Findings:  The physician reviewer found that there is a lack peer-reviewed literature supporting spectrum sound therapy program, including the Spectrum Achieve Level One (nature music) from Advanced Brain Technologies for in-home use and pre-writing therapy program to assist with fine motor strengthening and manipulation from Handwriting without Tears for in-home use as medically necessary in this clinical setting. Auditory Integration Training (AIT) involves a person listening to a selection of music which has been electronically modified. There are several kinds of AIT including the Berard Method, the Listening Program, the Samonas Sound Therapy, and the Tomatis Method. AIT is based on the idea that some people, including some people with autism, are hypersensitive or hyposensitive to certain frequencies of sound. AIT is designed to improve the persons ability to process sounds by re-educating the brain. A systematic review of publications in the field of AIT showed no evidence for long-term benefits. Furthermore, a study suggest that Handwriting without Tears is useful in general education and in children with Down syndrome. However, in this case there is a formal occupational therapy evaluation was not provided showing the patients current developmental level and whether an intervention to teach handwriting is appropriate. 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 physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 reimbursement for vest airway clearance system for treatment of the enrollee who was diagnosed with recurrent acute lower respiratory infection.Findings:  Three physician reviewers found that the patient had a diagnosis of mild upper lobe bronchiectasis and multiple pulmonary nodules. The patient has been treated with the Acapella device. The patients pulmonary function tests were normal and stable. Diffusion capacity per alveolar volume was also normal. Total lung capacity was normal. Oxygen (O2) saturation on room air at rest was 98% and with exertion to a heart rate of 151 per minute, the O2 saturation on room air was 95%. Her chest was clear. There was no ground glass lesions. The computed tomography scan of the chest did not have bronchiectasis of the lingula or right middle lobe. The provider recommended a vest airway clearance system for the treatment of this patients symptoms. The medical literature has not shown the superior efficacy of the device at issue in this clinical setting. The vest airway clearance system is a high frequency chest wall device for chest physical therapy.  It has been studied most frequently in patients with cystic fibrosis where daily chest physical therapy is generally accepted and deemed medically necessary.  The sputum in patients with cystic fibrosis is abnormal and the patients frequently have pulmonary infections with progressive decrease in pulmonary function.  However, there has been no documented superiority of the vest over routine chest physical therapy in any disease entity where the long term end point of the prospective clinical trial is a clinically significant outcome endpoint such as:  fewer hospitalizations for pulmonary infections, decrease in length of stay of a hospitalization or decrease in the progression of pulmonary disease.  The medical evidence appear to support that the vest is a convenience. There is a lack of randomized, controlled, clinical trials to prove efficacy and safety of the device at issue in this patients case. This patient does not have a diagnosis of cystic fibrosis or a neuromuscular condition affecting respiration. Final Result: Three reviewers determined that the device at issue was 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 internal medicine with sub-specialty certification in pulmonary disease 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for radiofrequency neurolysis. Findings:  The physician reviewer found that prior to performing radiofrequency neurolysis, dual diagnostic block testing is indicated. In this case, the patient has only had one set of diagnostic block performed. In addition, the requested radiofrequency neurolysis will not address the patients L5-S1 neuroforaminal stenosis.Final Result: Twp reviewers determined that the requested service 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 physician reviewers are board certified in anesthesiology with sub-specialty certification in pain medicine 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 TACE (transcatheter hepatic arterial chemoembolization) procedure for treatment of the enrollee who is diagnosed with bilateral breast cancer metastasized to the liver. Findings: Two physician reviewers found that her main site of metastases has been the liver. Her liver lesion was poorly differentiated adenocarcinoma with high expression of estrogen receptor. She had been managed on Doxil but then experienced an increase in liver tumors. The treating provider recommended TACE (transcatheter hepatic arterial chemoembolization) procedure as next step treatment options. The Health Plan denied the requested procedure noting that this procedure is investigational/experimental for the treatment of this patients medical condition. The medical evidence indicates that TACE is not a targeted therapy used for certain tumors only. TACE is commonly used for metastatic liver tumors which are not responsive to systemic chemotherapy like ocular melanomas, gastric cancers, carcinoid tumors, and others. The survival of patients with metastatic breast cancer is variable and local resection of metastases is considered standard of care, in some instances such as the case under discussion. The approach to stage IV breast cancer and liver-directed therapy has been reviewed in clinical studies and the evidence suggest a survival advantage in such patients when TACE is used as a treatment option. Therefore, in this patients case, the medical evidence supports the superior efficacy of this procedure over the other available treatment options.Final Result: The reviewers determined that the requested procedure 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: All three reviewers are board certified in internal medicine with sub-specialty certification medical oncology 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 authorization and coverage for Zepatier 50/100 mg for 12 weeks. 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, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1b patients should be treated with regimens including Zepatier for 12 weeks, regardless of NS5A resistance-associated testing. These guideline recommendations are based on clinical trial results showing high cure rates regardless of NS5A resistance. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. Final Result: The reviewer determined that the 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 reimbursement for inpatient psychiatric hospitalization provided for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the inpatient psychiatric hospitalization provided was medically necessary for treatment of the patients medical condition. The inpatient hospitalization was reasonably expected to improve the patients condition and prevent a more serious episode of illness for this patient with multiple intrapsychic conflicts and distorted schemas that exacerbated debilitating anxiety and clinical depression with atypical features, and fueled cyclical maladaptive patterns of behavior. Although the patient had showed some improvement in the first week, she had not championed the issues that prompted the admission. Indeed, she remained anxious and ruminative, and continued to sleep excessively. Further, she had yet to have any significant change in her medication regimen. The patient would have more than likely experienced a prompt deterioration if discharged. All told, inpatient psychiatric care was safe, appropriate and consistent with good medical practice in this case while the duration of services aligned with community standards. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition. 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.