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 Adderall for treatment of the enrollees idiopathic hypersomnia. Findings: The physician reviewer found that in this case, the generally accepted standard of practice supports the use of Adderall as prescribed for treatment of this patients idiopathic hypersomnia. According to  American Academy of Sleep Medicine guidelines, amphetamine, methamphetamine, dextroamphetamine, methylphenidate, and modafinil may be effective for patients with daytime sleepiness due to idiopathic hypersomnia (Morganthaler, et al). Central nervous system stimulants and wake promoting agents are commonly prescribed for use in idiopathic hypersomnia (Chervin; Masri, et al). For these reasons, the requested Adderall is medically necessary for treatment of this patients sleep disorder.   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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.  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 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatment with Sovaldi and ribavirin is medically necessary for 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD).   Findings:  Two physician reviewers found that  for this patient, the requested procedure is not superior to the available standard therapy for treatment of his medical condition. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu, et al in Curr Opin Gastroenterol). Another evidence review concluded that further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). Adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). A peer-reviewed journal published a letter stating that there are 11 reports of endoscopically-confirmed LINX erosion through the esophagus in the publically-accessible FDA adverse events database (Bielefeldt, et al). Additionally, LINX is associated with severe dysphagia requiring endoscopic intervention (Sheu, et al in Surg Endosc). The available peer-reviewed literature does not definitively support the conclusion that LINX is likely to be more beneficial in this case than standard treatment of surgical fundoplication (Sheu, et al in Surg Endosc). Moreover, the American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on the available literature and relevant clinical guidelines, LINX is not likely to be more effective than other treatment options.  Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. Accordingly, digital 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 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:   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.
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:  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone. The additional three dimensional imaging allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue, offers increased cancer detection, and allows better characterization of possible masses, spiculation, and architectural distortion. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: Two 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:   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.
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 (HCV).  Findings:  The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). The records provided demonstrate that this patients life expectancy exceeds this limit. However, in this case, the provider requested a 12 week course of Harvoni.  In patients with viral loads less than 6 million IU/mL, an 8 week course of Harvoni is considered medically appropriate. Kowdley and colleagues state, `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. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` This patient is treatment-naive without cirrhosis and according to the study performed by Kowdley and colleagues there is no additional benefit to an extended 12 week course of Harvoni in this clinical setting. Therefore, Harvoni for 12 weeks is not medically necessary for treatment of this patients HCV.  Final Result: The reviewer determined that the requested medication regimen 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Buprenorphine for treatment of his chronic back pain. Findings:  The physician reviewer found that in this patients case, the requested Buprenorphine is not medically necessary for treatment of his medical condition. Current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. Based on a study by Mafi and colleagues, there are Well-established guidelines for routine back pain stress conservative management, including use of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen and physical therapy, but avoiding early imaging or other aggressive treatments, except in rare cases, such as acute neurologic compromise or other red flags, including a history of malignant neoplasms. Similar findings are reflected in a report by Karppinen and colleagues which states that Conservative decisions in the treatment of degenerative disk disease are based on interventions made for patients with chronic low back pain (LBP). There is convincing evidence that patient education, exercise therapy, and cognitive behavioral therapy are the cornerstones for the treatment of chronic LBP sufferers. Furthermore, these therapies work best in a multidisciplinary rehabilitation context. Pain medication is needed for most patients with degenerative disk disease, and surgery may be needed for a minority only. There are a variety of anticonvulsants and antidepressants considered adjunctive to pain management therapy. High dose opioids are associated with a high risk of dependence and tolerance; therefore, they are not recommended for treatment of chronic pain. Medical studies show that short-acting opiates are more likely to cause adverse outcomes. Therefore, based on the available medical literature and in consideration of the presented clinical records, Buprenorphine is not medically necessary for treatment of this patients medical condition.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 anesthesiology with sub-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 rhinoplasty for treatment of his nasal fracture and deviated nasal septum.  Findings:  The physician reviewer found that from the American Society of Plastic Surgeons (ASPS), reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. In addition, the ASPS noted that reconstructive rhinoplasty transforms nasal abnormalities or damaged nasal structures to a more normal state. In the medical literature, Howard and Rohrich noted that in patients with nasal airway obstruction, it is important to restore the nasal airway. This patient presents with evidence of residual deformity and nasal obstruction as well as symptoms following attempted treatment with nasal fracture reduction. His initial treatment consisted of nasal fracture reduction which was unsuccessful. The patient has nasal deformity and nasal airway obstruction as a direct result of an initial injury and failed treatment. Based on the patients complaints and review of the photographs, secondary nasal treatment is within the standard of care from a reconstructive standpoint. Consistent with these findings, the requested corrective rhinoplasty is reconstructive in nature and medically necessary for management of this patients significant nasal dorsal, nasal bone and septal deformity.  Final Result: The reviewer determined that the requested surgery is reconstructive in nature and medically necessary for treatment of the patients medical condition.  Credentials/Qualifications: The reviewer is board certified in plastic surgery 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 Sovaldi and Daklinza for treatment of his chronic hepatitis C virus genotype 3a.  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 regardless of interferon eligibility, therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based partially on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). In addition, a delay in treatment may result in decreased survival (Jezequel, et al). 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 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 transcranial magnetic stimulation (TMS) therapy for treatment of his behavioral health condition.  Findings:  The physician reviewer found that TMS is endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder. TMS tends to be very well tolerated with fewer barriers than electroconvulsive therapy. In this case, the patient has chronic recurrent affective illness. He has history of poor tolerability to psychotropic medication. Considering the medical records, endorsement from the APA and the support in the peer-reviewed literature, TMS represents a safe, appropriate treatment consistent with good medical practice in this clinical setting. TMS therapy would reasonably be expected to improve the patients condition and prevent a more serious episode of illness. As such, TMS therapy is medically necessary for treatment of the patients medical condition. 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 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that tomosynthesis provides radiologists the ability to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. In this case, the original screening mammogram was performed with two-dimensional imaging only. Therefore, the follow-up diagnostic exam which included tomosynthesis was indicated. Neither breast had been evaluated using tomosynthesis on the initial screening exam. The tomosynthesis utilized as part of the follow-up diagnostic exam allowed evaluation of the areas of concern identified on the original screening study, in addition to the entire breasts for the first time. For this reason, the tomosynthesis portion of the diagnostic exam was likely of greater benefit to the patient than had this exam been done with two-dimensional imaging alone. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an office visit with a dermatologist for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient is requesting evaluation by a dermatologist for a black lesion on the abdomen that has been present for one year.  The lesion was evaluated by the patients primary care physician who recommended dermatology evaluation.  The primary care physician already examined the lesion, determined that evaluation or treatment was outside the scope of her practice and recommended specialist evaluation.  This indicates that evaluation and treatment of the lesion are medically necessary.  Pigmented lesions on the skin, particularly when changing or new, can be indications of malignant melanoma or other atypical melanocytic lesions.  Malignant melanoma is a deadly skin cancer with metastatic potential.  Prognosis is dependent upon early diagnosis.  All told, the requested office visit with a dermatologist is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is board certified in dermatology 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.