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

Nature of Statutory Criteria/Case Summary:  An enrollee requested comprehensive orthodontic treatment of the adolescent dentition, oral/facial photographic images, and cephalometric radiographic image for treatment of her overbite, overjet, and anterior crowding.  Findings:  The physician reviewer found that the records document that this patient does have a malocclusion with increased overjet and an overbite. Orthodontic treatment is indicated for the guidance of the dentition and supporting structures to attain and maintain optimum relations in physiologic and esthetic harmony among facial structures. The current medical literature supports the requested services in this clinical setting. All told, the requested orthodontic treatment of the adolescent dentition, oral/facial photographic images, and cephalometric radiographic image is supported as dentally necessary for treatment of this 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 oral and maxillofacial 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 eight weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive patients with hepatitis C, genotype 1 infection, treatment with Harvoni is recommended.  It is advantageous to treat patients before they progress to cirrhosis.  Based on clinical guidelines and the current medical literature, Harvoni for eight weeks is medically indicated for the treatment of this patient.   Final Result: Two reviewers 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 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 laboratory testing (tumor necrosis factor antagonists) for evaluation of her Crohns disease.  Three physician reviewers found that in this case, the patient had symptoms while on Remicade, suggestive of loss of response.  Inadequate response or loss of response can occur for many reasons.  However, the appropriate method for determination of cause for symptoms while on therapy is not clear.  The use of the testing at issue to investigate inadequate response and direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management, whether by therapy change, continuation with increase in dose, or other means.  The effectiveness of Anser IFX in the management of Crohns disease compared with conventional courses of action remains unproven in clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold levels been established.  Studies have found that anti-infliximab antibodies can be transient and disappear over time, with many patients who have these antibodies maintaining their response.  All told, laboratory testing was not likely to have been of greater benefit than other methods of evaluation. Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three reviewers are board certified in 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 12 weeks for treatment of his treatment experienced chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. These 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for 12 weeks is medically necessary for treatment of this patients hepatitis C virus infection. Final Result: Two reviewers 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 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 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. Moreover, according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Therefore, Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an L4-5 laminectomy/discectomy/decompression for treatment of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The medical records document multilevel degenerative disc disease.  The patient is status post left-sided L4-5 hemi-laminectomy and discectomy and now has recurrent low back pain.  There is a lack of support for the requested services in this clinical setting.  The MRI in this case does not support the presence of a recurrent herniation.  Although the provider uses that term, the radiologist noted epidural scarring and not recurrent herniation.  The medical records do not include documentation of a recurrent L5 nerve root radiculopathy, either sensory or motor.  A repeat surgery would be most likely to relieve symptoms if a recurrent herniation were present or when there is documentation of radiculopathy. This patients MRI documents multilevel possible pain generators including those at thoracic level and lumbar levels with involvement of not only intervertebral disc but facet joint structures.  All told, the requested L4-5 laminectomy/discectomy/decompression is not medically indicated for the treatment of this patient. 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 a power wheelchair/power gurney for treatment of his multiple osseous deformities and severe scoliosis.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested power wheelchair. According to the medical literature, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. The determination of who will benefit is a matter of clinical judgement more than of adherence to criteria defined by the literature. In this case, the patient has profound deficits of functional mobility for which he depends on the modified power wheelchair that has been requested.  He has been using a power wheelchair for most of his life. He can use a power wheelchair safely and his abode can accommodate the device. Therefore, based on the clinical documentation submitted, a power wheelchair/power gurney is medically necessary for treatment of the patients medical condition.   Final Result: The reviewer determined that the requested equipment is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 12 weeks for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  Moreover, per AASLD/IDSA guidelines for high priority treatment include patients with fibrosis of Metavir F2. This patient has advanced disease and hence, treatment is medically necessary. Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing. Two 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 the medication Xiaflex for treatment of his Peyronies disease.  Findings:  Three physician reviewers found that Peyronies disease is caused by scar tissue which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this condition can cause penile curvature with erection.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The only options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested medication Xiaflex 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested a positron emission tomography (PET) scan for evaluation of his cavitary left lower lobe lung mass suspicious for malignancy.  Findings:  Two physician reviewers found that although PET is not the best modality to determine whether this mass is cancer or infection, in this circumstance, the mass is highly suspicious for cancer. Thus, the utility of the requested PET scan would be in staging this patients lung cancer. Further, the PET scan will help evaluate the patient for hilar or mediastinal lymph nodes with high metabolic uptake, suggestive of metastases. Moreover, many lung metastases with cavitary lesions are from the head and neck, which would also be evaluated with the requested PET scan. All told, the peer-reviewed medical literature supports the requested PET scan as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested diagnostic procedure is likely to be more beneficial for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is 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:  The parent of an enrollee requested group social skills therapy for medical treatment of the enrollees attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Findings:  The physician reviewer found that the medical literature noted that ADHD is a common developmental neurobiological condition of childhood characterized by age-inappropriate degrees of hyperactivity/impulsivity and inattention to tasks requiring sustained vigilance. ODD is an externalizing behavior disorder characterized by difficulties with emotional and behavioral regulation that frequently brings the patient into conflict with authority figures. The combination portends more severe symptom severity, daily impairment, and a more at-risk prognosis than either disorder alone. The medical literature reported that cognitive-functional group intervention appears to significantly improve daily functioning, executive function, and social functioning for patients who demonstrate clinical impairment. The medical literature reported that the age at which patients are most physically aggressive is 22 months. However, some patients fail to inhibit this normal aggression and by the time they are three or four years of age are showing signs of ODD. Evidence suggests that the risk of poor outcomes in antisocial patients is very high. The medical literature indicated that a review of children between 3 to 12 years old showed that behavioral and cognitive-behavioral group-based parenting interventions are effective for improving conduct problems and parenting skills in the short-term. Moreover, there is data demonstrating long-term benefits with regard to health and social outcomes. Thus, the requested group social skills therapy is supported as medically necessary for treatment of this 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 neurology with special competence in child neurology and sub-specialty certification in neurophysiology and epilepsy 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 Synthroid for treatment of her hypothyroidism.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Synthroid has been established. The documentation submitted for review demonstrates that the patient has had improvement in her symptoms when switched to brand name Synthroid. The patient reported jaw, back and neck pain and chest discomfort with generic levothyroxine. Hence, it is reasonable and medically necessary for this patient to be treated with Synthroid given improvement in her symptoms. For the reasons provided, the patients request for Synthroid is medically necessary. Final Result: The reviewer determined that the medication at issue was and 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 endocrinology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the knee for evaluation of her right knee pain.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. The documentation submitted for review does not demonstrate physical examination findings of joint looseness or tendon impingement. In addition, there is no documentation demonstrating the patient has tried and failed a course of physical therapy. Further, the medical records also do not indicate a trial of anti-inflammatory medication or acetaminophen for three or more weeks, which is standard of care treatment prior to MRI study. The patient should begin a course of conservative treatment, prior to an MRI being considered. Based on the medical literature and clinical documentation provided, the request for MRI of the knee is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology with sub-specialty certification in interventional 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.