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 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 nonliver-related conditions. The guidelines report that patients with cirrhosis such as this patient are highest priority for therapy. Per the guidelines, cirrhotic genotype 1 patients who have failed interferon-based therapy should be treated with Harvoni for 24 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. Furthermore, the AASLD/IDSA guidelines cite data showing decreased 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 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 percutaneous tibial nerve stimulation for the treatment of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Current guidelines recommend percutaneous tibial nerve stimulation as a third-line option for the treatment of overactive bladder in patients who have failed and/or cannot tolerate first-line and second-line treatment options. In this case, records provided do not document that first-line and second-line treatments have failed.  Thus, percutaneous tibial nerve stimulation was not likely to have been of greater benefit than other modalities.   Final Result: Three reviewers determined that the services at issue were 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 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 Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. With regard to the Health Plan alternative of Viekira Pak, there are two major and two moderate drug interactions between the components of Viekira Pak and the patients prescriptions. All told, the request for Harvoni is a more appropriate treatment option for this patient given potential drug-to-drug interactions and therefore 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Afirma Gene Expression Classifier testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that while a fine needle aspiration (FNA) biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. A relatively new test, the Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Therefore, the Afirma Gene Expression Classifier testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in endocrinology and metabolism 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 Stelara for treatment of his medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Recent data has demonstrated that in cases refractory to immune modulator and tumor necrosis factor (TNF) alpha inhibitors, Stelara is often effective.  In a recent observational study, 79 patients (65%) had a clinical benefit within three months of receiving Stelara.  Over a median follow-up period of 9.8 months, the cumulative probabilities that patients maintained the clinical benefit for 6 and 12 months after introduction of Stelara were 93% and 68%, respectively.  This patient has demonstrated active inflammation and has not responded to multiple therapies, including two classes of biologics.  All told, the requested medication, Stelara, is likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested medication 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anti-reflux surgery utilizing LINX Reflux Management System for treatment of her medical condition. Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies at four years are encouraging.  However, to date, the studies investigating LINX have been open label, observational studies.  There is a lack of head to head randomized trials with standard surgical treatment.  All told, the LINX Reflux Management System is not likely to be more effective than other treatment options. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in 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: 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 joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis.`  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested mental health services on an emergent or urgent basis. Findings:  The physician reviewer found that at issue in this case is whether the enrollee was experiencing a psychiatric emergency medical condition. A psychiatric emergency medical condition is defined as a mental disorder that manifests itself by acute symptoms of sufficient severity that it renders the patient as being either of the following: (A) an immediate danger to himself or herself or others  or (B) immediately unable to provide for, or utilize, food, shelter, or clothing, due to the mental disorder. Urgently needed services are defined as those services necessary to prevent serious deterioration of the health of an enrollee, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plans service area. In this case, the patient did not meet criteria for a psychiatric emergency medical condition as he did not pose an imminent danger to self or others and was able to appropriately utilize food, shelter and clothing. Based on the patients presenting symptoms, he was not experiencing a psychiatric emergency medical condition. However, the patients decision to seek medical attention was consistent with the actions of a prudent layperson. The patient urgently needed services to prevent a serious deterioration resulting from his existing condition, bipolar disorder, which represents a severe mental disease that has poor outcomes. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he needed urgent medical attention to prevent serious deterioration of his health. Thus, the services meet prudent layperson criteria for urgent care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for urgently needed services. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Entecavir for treatment of his medical condition.  Findings:  The physician reviewer found that Entecavir is medically necessary in this case, irrespective of the patients hepatitis B e antigen (HBeAg) status or current viral load. The goal of therapy is long term viral suppression.  The American Association for the Study of Liver Disease guidelines for treatment of hepatitis B state that for HBeAg-negative patients, relapse is frequent even when HBV DNA has been suppressed to undetectable levelsfor more than a year; thus, the endpoint for stopping treatment is unclear. If an HBeAg-positive patient is converted to negative for e antigen, it is unclear that entecavir therapy could be stopped. A peer-reviewed summary reports that there is lack of sufficient data on off-treatment durability of response, and that future studies are warranted toguide the timing of stopping therapy. In HBeAg-negative cases, the cumulative relapse rate one year after stopping entecavir treatment was 45.3%. As only 5% of HBeAg-negative patients clear surface antigen after five years of continuous therapy, life-long treatment is often required, and there is currently no safe and realistic endpoint for chronic hepatitis B therapy in those patients. A peer-reviewed summary states that most patients with chronic hepatitis B probably require lifelong oral antiviral treatmentthe goals of antiviral therapy are sustained suppression of HBV replication and hepatic inflammation, thereby improving long-term outcomes and prolonging patient survival by preventing the development of progressive fibrosis, cirrhosis and/or hepatocellular carcinoma. Entecavir-mediated viral suppression has been shown to decrease the risk of decompensation, hepatocellular carcinoma, and death. Therefore, the goal of treatment is long-term viral suppression and the requested medication is indicated in this clinical setting.  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 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 the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This guideline recommendation is based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. For these reasons, the 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his chronic hepatitis C virus.  Findings:  The physician reviewer found that per 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. According to the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety. The guidelines also cite data showing decreased survival with delayed therapy . For these reasons, the requested treatment with Viekira Pak 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: An enrollee has requested hip surgery for treatment of her medical condition.   Findings:  The physician reviewer found that researchers reported on a series of surgical interventions with arthroscopic endoscopic repair of partial or full thickness tears combined with bursectomy. The authors state that their findings need to be confirmed by clinical studies with longer follow-up and that the degree of tendon degeneration may compromise any attempts to repair the lesion present. Based on the documentation submitted for review, the patient has substantial and significant comorbidities. Any surgical intervention would likely have low efficacy and high risk of complications, such that it is not likely to be beneficial. Based on the peer-reviewed literature and clinical documentation the requested hip surgery is not clinically indicated for the treatment of the patients medical condition.  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 reviewer is board certified in orthopedic 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 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 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 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 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.