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

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential behavioral health services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the requested residential behavioral health services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, there is a lack of support demonstrating symptoms or interventions which would require 24-hour level of monitoring for this patient. There is a lack of evidence demonstrating mood dysregulation which would prevent him from safely continuing at a lower level of care. Moreover, there is a lack of evidence to support that the patient has a psychiatric disorder that affects all areas of functioning that require residential level of care. All told, the patient could have been safely treated at a lower level of care.  Final Result: The reviewer determined that the services at issue were not and 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 with sub-specialty certification in child and adolescent 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 rituximab for treatment of his medical condition.  Findings: Two physician reviewers found that rituximab is likely to be more beneficial for treatment of the patients medical condition than other modalities. This patient has been treated with the standard treatment options for minimal change nephrotic syndrome and focal segmental glomerulosclerosis (MCNS/FSGS) including steroids, cyclophosphamide and cyclosporine with frequent relapses of nephrotic syndrome. The case study by researchers concluded that rituximab may be effective treatment for refractory steroid resistant nephrotic syndrome with FSGS. Based on the reasons provided, rituximab is likely to be more beneficial for treatment of the patients medical condition than any available modalities.  Final Result: Two reviewers determined that the medication at issue was and 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: One reviewer is board certified in pediatric nephrology and is actively practicing. Two physician reviewers are board certified in internal medicine with sub-specialty certification in nephrology 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 the Afirma Gene Expression Classifier for evaluation of his medical condition. Findings:  Two physician reviewers found that the Afirma Gene Expression Classifier is designed for use in patients with indeterminate cytology, such as follicular cell of undetermined significance or atypia of undetermined significance. In this case, the Afirma testing was not indicated. In this case, the cytology was consistent with respiratory epithelial cells. The Afirma test is useful for indeterminate nodules as it decreases unnecessary surgeries in patients with indeterminate nodules who have benign Afirma testing. Afirma testing is indicated for patients with a specific cytology. Given this patient presented with respiratory epithelial cells, the Afirma testing was not indicated. Final Result: Two 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 internal medicine with sub-specialty certification 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program level of care of behavioral health services for eight to ten weeks, with concurrent reviews beginning after three weeks and every week thereafter for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has a history of unpredictable, violent behavior.  She made minimal progress in the residential treatment setting.  Based on the records, intensive outpatient program level of care would not provide adequate structure for this patient who is imminently dangerous not only to herself, but to those around her.  In this clinical setting, partial hospitalization program represents the lowest level of care that can provide adequate treatment in that it provides daily structure for patients with explosive violent urges.  However, the records do not demonstrate the medical necessity of the requested duration of partial hospitalization level of care.  Per the medical records, an initial four weeks of partial hospitalization program level of care with concurrent review at the two-week mark is medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 Daklinza for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to 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. Patients with cirrhosis are considered to be highest priority for therapy. In cirrhotic treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-3 study, which showed a cure rate of 90%. Per the guidelines, only interferon-eligible patients can be treated with Sovaldi, peginterferon, and ribavirin. This patient is interferon-ineligible due to a pre-existing medical condition. Delay in treatment may result in decreased survival. For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.   Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   The reviewer is 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 residential treatment center services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that this case presents a complex uniqueness that manifests with a complicated level of care determination. The outpatient providers who best know this case have recommended residential treatment as the patient has not adequately responded to comprehensive outpatient based services. Further, the psychiatrist acknowledged the diagnostic challenges in discerning bipolarity from character pathology. Considering the patients symptom burden, uncertain diagnostic assessment, failure of treatment in a less restrictive setting and the clinical recommendation rendered by her treatment team, admission to a residential program would be safe, appropriate and consistent with good medical practice. This patient will require long-term specialty treatment, but a short duration of treatment in a residential setting would be reasonably expected to improve her condition, refine the diagnosis and galvanize a recovery-oriented treatment plan that can be continued in a community based setting.  The length of stay should be determined based on the patients treatment needs and clinical progress within the programmatic setting. This is of particular importance in this case as there was concern that groups may have exacerbated her illness expression in the past. Thus, the admission would be subject to standard review processes to determine the appropriate length of stay.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy for treatment of his medical condition.  Findings:  Three physician reviewers found that proton beam radiation therapy is not likely to be more beneficial than standard therapy consisting of conventional fractionated photon therapy.  For a subtotally resected grade 1 meningioma, the medical evidence supports fractionated external beam radiation with photons to a total dose of 45 to 54 Gy, or consideration of stereotactic radiosurgery if deemed safe.  In this dose range, the potential benefit of proton therapy due to its Bragg Peak and sharper dose fall off is not likely to be clinically relevant.  Thus, the requested proton beam radiation therapy is not likely to be of greater benefit than other treatment alternatives.  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 radiation oncology 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 Opdivo (nivolumab) for treatment of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the requested medication in this clinical setting.  Opdivo is not supported for the treatment of metastatic colon cancer by major drug compendia.  The current medical literature does not demonstrate the superior efficacy of the requested medication in this patients case.  Based on the submitted documentation, Opdivo is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 Gilenya for treatment of her medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the patient has evidence of clinically definite multiple sclerosis. A patients treating provider determines the best therapy for multiple sclerosis patients based on many different factors, including age, disease activity, MRI findings (ongoing active disease as demonstrated by enhancement), family history, presenting features, and co-morbid disease. The study by researchers compared the effect of oral immunomodulator fingolimod with all injectable immunomodulators (interferons or glatiramer acetate) in patients with active multiple sclerosis. They demonstrated that Gilenya is better than platform agents. In addition, Gilenya is recognized as one of the more highly active multiple sclerosis treatments, and general consensus among many multiple sclerosis specialists is that it is more effective than platform agents, such as interferons and Copaxone. Gilenya is U.S. Food and Drug Administration (FDA) approved for the treatment of relapsing forms of multiple sclerosis and is indicated for patients at any stage of their disease. There is a lack of clinical evidence to suggest that treatment with Gilenya should be held until a patient has tried and failed other disease modifying agents. All told, the medical necessity for treatment with Gilenya has been established 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 physician reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the 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, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. 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 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 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. In addition, the patient is not eligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a pre-existing condition, which can be exacerbated by ribavirin.  AASLD/IDSA 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 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 Prometheus Anser ADA Diagnostic Testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that in theory, this method of testing could allow for personalized care in which the drug level is optimized based on individual results.  However, in clinical practice, these tests fall far short.  Patients fail on a biologic for a number of reasons, including the presence of a surgical complication of disease.  In other cases, patients do not respond even with an optimized level as their disease is refractory to anti-tumor necrosis factor treatment.  Per the medical evidence, the testing at issue has not been shown to be superior to routine clinical care.  All told, Prometheus Anser ADA Diagnostic was not likely to have been of greater benefit than other methods of evaluating this patient.  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 Daklinza for treatment of his hepatitis C virus. Findings:  The physician reviewer found that pursuant 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. In this case, the patient is ineligible for ribavirin due to a pre-existing condition that proved to be exacerbated in a placebo-controlled trial of ribavirin monotherapy. AASLD/IDSA guidelines only recommend one regimen for treatment-naive ribavirin-ineligible genotype 2 patients: Daklinza and Sovaldi. The guidelines state that consideration of extending treatment to 24 weeks for patients with poor baseline characteristics is reasonable. This recommendation is based on two clinical trials. For these reasons, the requested Daklinza is supported as medically necessary for 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.