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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week course of Harvoni for treatment of her 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: 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 eating disorder partial hospitalization program services for treatment of her behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient was unable to adhere to her meal plan and refrain from purging.  She evidenced characterological pathology, but her eating disordered behavior continued to dominate her daily routine and contribute to signs and symptoms such as dizziness, orthostatic changes and hypertension.  The patient continued to restrict caloric intake and purge despite services being provided in the program, and there was no indication that this behavior would lessen.  Of further import, the patient had significant medical and psychiatric comorbidities which complicated the clinical picture.  She had limited social support and strained family dynamics.  Given these factors, the patient was at high-risk for relapse in the event of a premature discharge.  The partial hospital setting remained reasonably expected to improve her condition while preventing a more serious episode of illness.  In sum, the partial hospitalization program services represented a safe and appropriate disposition consistent with good medical practice.  All told, partial hospitalization services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Per the guidelines, daily Sovaldi and weight-based ribavirin are recommended for treatment-naive and treatment-experienced patients with hepatitis C, genotype 2 infection.  All told, Sovaldi and ribavirin for 12 weeks are medically indicated for the treatment of this patient. Final Result: Three reviewers 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for morphine sulfate for treatment of her chronic pain. The physician reviewer found that the current medical evidence does not support the requested medication in this clinical setting.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of high-dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested morphine sulfate is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the enrollees medical condition.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty 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 Harvoni for 12 weeks or 8 weeks of Harvoni in the alternative for treatment of her chronic hepatitis C virus genotype 1.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested in-home therapy service for behavior modification with a psychotherapist for treatment of the enrollees behavioral health condition.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. According to Antshel Although stimulant medications represent an evidence-based approach to managing ADHD, psychosocial interventions for child/adolescent ADHD target functional impairments as the intervention goal, and rely heavily on behavioral therapy techniques and operant conditioning principles. Evidence-based psychosocial interventions for managing pediatric ADHD include behavioral parent training, school-based interventions relying on behavioral modification, teaching skills, and operant conditioning principles, and intensive summer treatment programs. Behavior treatment includes both social and psychological therapies and often involves medical, educational, and behavioral treatments used together. In this case, the medical necessity for in-home therapy service for behavior modification with a psychotherapist has not been established for 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 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 risk for breast cancer.   Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone or any available standard modality.   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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested the iStent trabecular micro-bypass procedure for treatment of his medical condition. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  This patient had visually significant cataract and poorly controlled glaucoma on medical therapy.  The use of iStent has been approved for the treatment of this patients condition.  There is good evidence in the medical literature in controlled clinical trials over two years duration that treatment with the iStent is safe and effective for the patients disease.  The standard therapy of cataract surgery alone with continued topical medication is not as effective for treating the patients glaucoma.  All told, iStent trabecular micro-bypass procedure was likely to have been superior over other treatment options.  Final Result: Three reviewers determined that the services at issue were 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 ophthalmology 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 nasal endoscopic surgery for treatment of the enrollees sinusitis.  The physician reviewer found that while sinus ostial dilation may be an appropriate therapeutic option for patients with chronic sinusitis, the criteria have not been met in this patient. The indication for sinus surgery is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. In addition, the guidelines noted that chronic rhinosinusitis is characterized by two or more symptoms, one of which is nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, and/or polyps and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis has not been documented in this patient. There was no documentation of the chronology of her disease and there is a lack of radiographic evidence supporting the diagnosis of chronic sinusitis warranting sinus surgery. Therefore, the requested nasal endoscopic surgery is not medically necessary in this patient. Final Result: The reviewer determined that the requested surgery 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 otolaryngology 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 Harvoni for 24 weeks for treatment of his chronic hepatitis C virus genotype 1b.  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) guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For ribavirin ineligible treatment naive patients with decompensated cirrhosis and genotype 1 hepatitis C, the guidelines recommend Sovaldi with Daklinza for 12 weeks. The only Harvoni regimen recommended in decompensated genotype 1 patients requires the use of ribavirin. Although treatment of this patient is important and high priority, the AASLD/IDSA guidelines do not support the requested Harvoni for 24 weeks as medically necessary for treatment of this patients hepatitis C virus. 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 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 a consultation with a perinatologist, an ultrasound conducted by the perinatologist, and fetal echocardiography for treatment of her early pregnancy hemorrhage.  Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. In this case, the patient does not have any medical or pregnancy conditions that require a referral for a consultation with a perinatologist. Although she experienced vaginal bleeding, this resolved without treatment. In addition, two ultrasounds showed normal maternal, fetal and placental anatomy. According to the American Institute of Ultrasound in Medicine (AIUM), an ultrasound assessment of fetal anatomy is indicated but does not need to be conducted by a perinatologist.  Similarly, a fetal echocardiography is not medically necessary as there is no related family history and no medical problems or medication exposures that would increase the risk of cardiac malformations in this fetus. Based on the clinical documentation submitted, a consultation with a perinatologist, an ultrasound conducted by the perinatologist and fetal echocardiography are not medically necessary for 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 obstetrics and gynecology with sub-specialty certification in maternal and fetal 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 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested group speech therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that with the change to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) there is recognition that language delays or language disorders is a separate problem from the autism spectrum disorder. However, with the change to DSM-5 there is also the recognition that pragmatic or group social language deficits are a significant part of the autism spectrum disorder. In this case, the group speech therapy progress reports demonstrate that this patient has made measurable gains from therapy. Moreover, the patients most recent evaluation showed above average pragmatic language skills for age. In this clinical setting, the Health Plans recommendation for continued ABA to address the patients social skills is medically reasonable and appropriate. For the reasons provided, continued group speech therapy is not medically necessary in this clinical setting.  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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.