Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested BRCA genetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that per the National Comprehensive Cancer Network (NCCN) guidelines BRCA testing is indicated for an individual that has been diagnosed with breast cancer at any age and at least one first degree family member diagnosed at the age of 50 or younger. This patient meets criteria for BRCA testing per NCCN guidelines. Thus, BRCA genetic testing was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that tomosynthesis provides advantages to radiologists in the interpretation of digital mammography. Tomosynthesis has the ability to separate architectural distortion from underlying malignancy/mass. This advantage is important in this particular case in light of the post lumpectomy architectural distortion in the left breast. Post lumpectomy architectural distortion may be difficult to differentiate from the distortion associated with malignancy/recurrence.  This was likely more possible with the addition of tomosynthesis than had the exam been done with two-dimensional imaging only.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in 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: Upheld 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. Findings:  The physician reviewer found that per the guidelines, all patients with chronic active hepatitis C virus (HCV) 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 as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. While the patient is an appropriate candidate for antiviral therapy, the proposed treatment regimen of Harvoni for 12 weeks is not medically necessary to successfully treat his condition. A study by medical researchers showed no difference in sustained viral response between 8 and 12 weeks of treatment in patients without cirrhosis and whose HCV viral load was less than 6 million IU/mL. As such, 8 weeks of Harvoni as opposed to 12 weeks is medically appropriate in this clinical setting. Thus, the proposed regimen of 12 weeks of Harvoni is not medically necessary for treatment of the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a tracheal shave for treatment of her gender dysphoria.  The physician reviewer found that review of the submitted clinical documentation demonstrates the patient is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. The submitted photographs depict a significantly prominent thyroid cartilage, which is more consistent with male anatomy. According to Capitan and colleagues, The principal differences between masculine and feminine facial features are related to the bone structure, although other important differentiating characteristics also exist, such as skin type, distribution of facial hair and fat, type of hair and hairline shape, the prominence of the thyroid cartilage or Adams apple, and differentiating characteristics in the soft tissues, among others. Furthermore, tracheal shave is considered part of the customary surgical treatment for male-to-female transition. In this patients case, medical necessity for the proposed tracheal shave has been adequately established by the submitted medical documentation and review of the patients photographs. Moreover, the proposed procedure is considered reconstructive surgery in this setting. In this case, the patient's prominent thyroid cartilage is considered abnormal for a female. This abnormal structure of the body is a result of the patients well-documented gender dysphoria. The proposed tracheal shave would help to create a more normal appearance for an individual of the female gender and is likely to provide more than minimal improvement in the patients appearance. As such, the requested tracheal shave meets criteria for reconstructive surgery.  Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in plastic 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 inpatient psychiatric hospitalization for treatment of his behavioral health condition.  Findings:  The physician reviewer found that psychotic illnesses are chronic conditions that commonly demand multiple psychiatric hospitalizations over the course of a lifetime. However, psychiatric interventions provide a realistic expectation for meaningful recovery, allowing patients to live independently in the community of their choosing. In this case, the patient has not decompressed the symptom burden that prompted the admission and is not stable for transition to a less restrictive treatment setting. Further, he remains engaged in active treatment that is reasonably expected to improve his condition and prevent a more serious episode of illness. In addition, both the clinical care and treatment setting was and is safe, appropriate and consistent with good medical practice.  Thus, the services at issue were and are medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were and 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his medical condition. Findings:  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.  Chronic pain may worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  Researchers 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.  Other researchers reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects.  All told, the requested Norco 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 patients medical condition. Therefore, the Health Plans denial should be upheld.   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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment for the treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  There was documentation presented from her prior treatment outlining her history.  However, there was a lack of details provided regarding her reported substance use in terms of patterns, actual substances used, or quantification.  On admission, self-medication was endorsed.  However, this also was not described in detail, so it cannot be determined what, if any, impact it would have had on her daily functioning.  She had no history of failure at a lower level of care.  From the time of admission and throughout her stay, she was an active and engaged participant in group, individual, and family therapies.  Her medication regimen did not require residential level of care, and she had no medical comorbidity.  All told, residential treatment was not and is not medically indicated for the treatment of this patient.   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 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.  Findings:  The physician reviewer found that according to 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 should be treated except those with life expectancy less than 12 months due to non-liver-related conditions.  In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia during a colonoscopy for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  There is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia during a colonoscopy was not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. This is based on the SYNERGY trial for Harvoni. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy.  For these reasons, treatment of the patients hepatitis C at this time is indicated, and treatment with Harvoni is medically necessary in this case. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis has resulted in a decrease in callbacks and increase in detection of small cancers when the technique is used in conjunction with two-dimensional imaging.  The addition of breast tomosynthesis to digital mammogram has gained endorsement by radiologists due to the added advantages.  All told, the addition of breast tomosynthesis was likely more advantageous to this patient than had the mammogram been done with two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in 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: The parent of an enrollee has requested group speech therapy services and social skills for treatment of the enrollees medical condition. Findings:  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. Group speech therapy services and social skills are indicated to address the social skills deficits with the patients peers. The patient presents with good expressive and receptive language skills. However, standardized tests do not pick up the problems with social communication that is seen in a child with autism spectrum disorder.  According to the American Academy of Pediatrics People with ASDs have deficits in social communication, and treatment by a speech-language pathologist usually is appropriate. Most children with ASDs can develop useful speech, and chronologic age, lack of typical prerequisite skills, failure to benefit from previous language intervention, and lack of discrepancy between language and IQ scores should not exclude a child from receiving speech-language services. However, traditional, low-intensity pull-out service delivery models often are ineffective, and speech-language pathologists are likely to be most effective when they train and work in close collaboration with teachers, support personnel, families, and the child's peers to promote functional communication in natural settings throughout the day. In this case, group speech therapy services and social skills are medically necessary for treatment of the patients social skills and functional conversation speech skills. For the reasons stated, group speech therapy services and social skills are 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for the treatment of his hepatitis C.  Findings:  The physician reviewer 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 due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. For these reasons, the requested treatment with Viekira Pak and ribavirin 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lap sleeve gastrectomy for treatment of her medical condition. Review of the submitted documentation fails to establish the medical necessity of the requested surgery. In this case, the patient previously underwent laparoscopic adjustable gastric band surgery with removal due to reflux. There is a lack of documentation provided supporting the requested surgery. There is no documentation demonstrating six months of supervised weight loss, or a multidisciplinary evaluation with psychological and dietary clearance. Moreover, there is no documentation of a technical complication of bariatric procedure that requires surgical intervention. For the reasons provided, the request for lap sleeve gastrectomy is not medically necessary for treatment of the patients medical condition.  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 general 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.