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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Maxalt for treatment of her migraine headaches  The physician reviewer found that Maxalt (rizatriptan) is an effective medication in the triptan class to treat acute migraine. Rizatriptan is a small molecule and therefore there should not be any significant difference between generic and branded drugs. The patient indicates that the generic form does not work and she has increased headaches. However, this is not supported in the medical records submitted for review. According to the American Headache Society, any patient with four or more migraines a month should be considered for preventive therapy which may help reduce the number of headaches and often allows the headaches to be more amenable to acute therapy. In this case, it does not appear she is under the care of a neurologist or headache specialist. Given the lack of documentation demonstrating that the patient has failed generic rizatriptan, the brand name Maxalt is not medically necessary for treatment of the 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 neurology with sub-specialty certification in headache 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: The parent of an enrollee requested applied behavioral analysis (ABA) therapy utilizing the Lovaas technique for treatment of the enrollees autism spectrum disorder.  Findings:  Three physician reviewers found that Autism is a complex neurological disorder characterized by restricted repetitive patterns of behavior, as well as variable deficits in speech/language and social interaction. Deficits in fine and gross motor skills and processing of sensory and motor information are also common.  ABA therapy is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism. Behavioral approaches are considered to be first-line treatment for autistic spectrum disorders, along with speech and language therapy. The medical literature reported a systematic review of empirical studies of treatment programs for children with autism. The authors found that only interventions based on applied behavior analysis (ABA), specifically those based on the Lovaas model, met predetermined, published criteria for being well-established treatments. Based on the support in the medical literature, ABA therapy utilizing the Lovaas technique is medically necessary for this patient.Final Result: Three reviewers 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: Reviewer 1 is board certified in pediatrics and pediatric critical care and is actively practicing. Reviewer 2 is board certified in neurology with sub-specialty certification in child neurology and is actively practicing.  Reviewer 3 is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an intensive inpatient pain management program for treatment of her fibromyalgia, fatigue and chronic headaches.  The physician reviewer found that the request for an intensive inpatient pain management program is medically necessary for treatment of the patients medical condition. There is support for the requested services in the medical literature. The study by Angst and colleagues states Intensive interdisciplinary rehabilitation with more behavioral therapies was accompanied by a greater improvement in patients who were severely affected by pain, compared with standard rehabilitation by the end of the stay. Angst and colleagues also stated that Inpatient, structured interdisciplinary rehabilitation covering elements of cognitive and operant behavioral therapy, graded activity exercise, and adapted drug therapy revealed moderate to large short-term and mid-term improvements in physical and mental health and in the major coping dimensions as captured by comprehensive and specific assessment. In this case, the medical records submitted for review indicate a condition of chronic pain that has not responded to multidisciplinary care that includes medication management and psychological therapy and biofeedback. The medical records support that the patient is currently on chronic opioids.  Inpatient pain rehabilitation is the preferred course of therapy for patients who have chronic pain that has failed other conservative care. As such, the requested intensive inpatient pain management program is supported as consistent with guidelines for chronic pain management and medically necessary in this clinical setting. 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 and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested carvedilol for treatment of her congestive heart failure. The physician reviewer found that based on the records provided, the patient has hypertension as well as reference to congestive heart failure. In this clinical setting, treatment with beta-blockers is indicated. However, hypertensive guidelines endorsed by several national organizations do not support a compelling medically necessary indication for the use of carvedilol over other beta-blocker medications. In addition, studies evaluating the use of beta-blockers in patients with congestive heart failure have demonstrated improved outcomes compared to several medications including bisoprolol, metoprolol and carvedilol. Therefore, the requested carvedilol is not supported as medically necessary for treatment of this patients hypertension.  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 cardiology 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 pencil proton beam therapy for treatment of his prostate cancer. The physician reviewer found that pencil proton beam therapy is not medically necessary for treatment of the patients medical condition. Pencil beam proton therapy utilizes a circular collimated beam that irradiates the target in a volumetric piecemeal fashion, as opposed to scattering beam proton therapy which utilizes collimated and compensated shaped beams. A proton is the charged nucleus of a hydrogen atom. Charged particles can be used to deliver therapeutic radiation.  Standard radiation is delivered with a linear accelerator (LINAC), which delivers photon therapy (akin to high energy light), while protons (and other charged particles) are generated from a cyclotron.  The difference between proton and photon irradiation is that the protons (or charged particles) stop abruptly in the tissue (Bragg peak) so there is less exit dose through normal tissue. The depth of proton delivery is more susceptible to changes in tissue density, such as changes of air in the rectum. Given these issues, there is also the possibility that proton therapy is disadvantageous. A study by Sheets and colleagues shows that proton therapy has resulted in a greater risk of gastrointestinal toxicity versus intensity-modulated radiation therapy (IMRT). Thus there is compelling data showing worse outcomes with proton therapy. Moreover, the generally accepted standard of care for prostate cancer is to only offer proton beam therapy on clinical trials, and to not routinely offer it to patients. Thus, the patients request for pencil proton beam therapy is not medically necessary fort treatment of the patients prostate cancer. 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 radiation oncology 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 a dermatology consultation for evaluation of her changing mole.  The physician reviewer found that according to the documentation from the primary care providers notes, the patients mole in question does not exhibit any concerning signs or symptoms for skin cancer. The patient reports that the mole has been enlarging. She also stated that her mother passed away secondary to skin cancer. However, based on the documentation provided, the requested referral for consultation with a dermatologist is not medically necessary in the absence of any concerning signs or symptoms for skin cancer. Final Result: The reviewer determined that the requested referral is 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 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.
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 hepatitis C virus (HVC).  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 genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials. In addition, the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C Genotype 1 regardless of fibrosis stage. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. 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 AmniSure testing for evaluation of her pregnancy. Three physician reviewers found that the AmniSure test is used to aid in the detection of rupture of membranes when a patient reports signs, symptoms or complaints suggestive of rupture of membranes or premature rupture of membranes.  The diagnosis of rupture of membranes is typically confirmed by visualization of amniotic fluid passing from the cervical canal and pooling in the vagina, as well as a basic pH test of the vaginal fluid.  In this patients case, the records do not support that standard evaluation of possible rupture of membranes would have been insufficient.  Therefore, AmniSure testing was not likely to be 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 obstetrics and gynecology 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 three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is adequate support in the medical literature to support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. According to the study by Skaane and colleagues The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. As such, 3D breast tomosynthesis 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested 12 weeks of Harvoni for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.   Final Result: Three 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 eight weeks of Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reiewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given these findings, the requested eight week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.  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 food allergy testing for evaluation of his medical condition.  Two physician reviewers found that the use of food-specific IgG level does not predict true food hypersensitivity, and may actually be a marker of earlier development of food tolerance.  Food-specific IgG tests typically yield multiple positive results and may represent a normal immune response to foods.  The standard evaluation of food allergy consists of blood IgE level for foods and skin testing.  IgE immunoassays are in vitro assays used to identify food-specific IgE in the serum.  These tests are widely available, and immunoassays have demonstrated very high positive predictive accuracy for several of the major food allergens.  Values have been established for egg, milk, peanut, tree nuts, and fish that correspond to a positive predictive accuracy of 95%.  Skin testing for food-specific IgE is used in the diagnosis of IgE-mediated food allergies.   A positive skin test to a particular food indicates the possibility that the patient has true allergy to that food.  In conclusion, food allergy testing (IgG food laboratory testing) was not likely to have been superior over other methods of evaluation. Final Result: Two 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:  One reviewer is board certified in dermatology and is actively practicing. Two reviewers are board certified in internal medicine and allergy and immunology 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:   The parent of an enrollee has requested growth hormone (GH) therapy with Genotropin for treatment of the enrollees short stature. The physician reviewer found that according to the Lawson Wilkins Pediatric Endocrinology Society guidelines, a trial of GH therapy should be approved for children with otherwise unexplained short stature who pass GH stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of GH deficiency. This patient meets at least four of these criteria. Provocative GH tests have poor sensitivity and specificity for the diagnosis of GH deficiency, so the normal response to testing is not reassuring in the setting of auxological evidence of growth failure, low growth factors, and a markedly delayed skeletal maturation. All told, the medical records support the requested GH therapy with Genotropin as medically necessary for treatment of this patients short stature.  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 pediatric 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.