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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional 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 allows radiologists to separate dense glandular tissue from architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  The medical literature supports breast tomosynthesis in this patients case.  All told, the addition of three-dimensional breast tomosynthesis was more likely to be beneficial to the patient than had the mammogram been done with the two-dimensional technique 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested emergency room services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates there were no signs of serious medical illness or discomfort in this patient. There is no evidence of pain, fever or systemic symptoms, and the patient had no underlying medical conditions. Based upon the chart notations, the patient did not appear uncomfortable in any way. A prudent layperson in this situation would not have believed the patient was experiencing an emergency medical condition. While the patients parent noted concerns about infection, the patient did not present with acute symptoms of infection. In this situation, a prudent layperson would have scheduled an appointment with the patients pediatrician on an outpatient basis. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: 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:  Three physician reviewers found that in this patients case, the services at issue were likely to have been more effective than other methods of evaluation.  Per the medical evidence, breast tomosynthesis is of particular benefit for evaluating patients with extremely dense or heterogeneously dense tissue.  The utility of the new technique relates to the ability to separate dense glandular tissue from architectural distortion.  The result is a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of the technique was likely of more benefit to the patient than had the mammogram been done with two-dimensional imaging alone. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of her hepatitis C virus. Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active 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. Combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving proposed genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, the requested Sovaldi is medically necessary for treatment of the patients medical condition.  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 his 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. Per the guidelines, patients who have failed treatment with pegylated interferon and ribavirin are recommended to be re-treated with daily Harvoni for 12 weeks. This is based on multiple clinical trials.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni is supported as 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: 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 in this patients case, the medical evidence has demonstrated the superior effectiveness of the services at issue.  Breast tomosynthesis allows radiologists to separate dense glandular tissue from underlying architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Based on the submitted records, the addition of breast tomosynthesis to screening digital mammogram was likely of greater benefit to the 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Fetal Aneuploidy Trisomy Risk testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Obstetricians and Gynecologists has recommended that cell-free fetal DNA can be used as a primary screening test in women at increased risk of aneuploidy.  This includes women aged 35 years or older, women with a positive first-trimester or second-trimester screening test result, fetuses with ultrasonographic findings that indicate an increased risk of aneuploidy, women with a history of a child affected with a trisomy, or a parent carrying a balanced robertsonian translocation with increased risk of trisomy 13 or trisomy 21.  This patient did not meet any of these criteria.  Thus, Fetal Aneuploidy Trisomy Risk testing was not likely to have been superior over other methods of evaluating this patient.  Final Result: Three physician 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 physician 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested emergency surgery and related services on an emergent or urgent basis. Findings:  The physician reviewer found that according to the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines for the Management of Hiatal Hernia, once the diagnosis of reflux is objectively confirmed, `surgical therapy should be considered in individuals who: 1) have failed medical management (inadequate symptom control, severe regurgitation not controlled with acid suppression, or medication side effects) or 2) opt for surgery despite successful medical management (due to quality of life considerations, lifelong need for medication intake, expense of medications, etc.) or 3) have complications of GERD (e.g., Barretts esophagus, peptic stricture) or 4) have extra-esophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration).` SAGES urges caution rather than urgency in pursuing surgical intervention. Specifically, the guidelines note the `average mortality rates for emergency hiatal hernia surgery are around 17% [whereas] the risk of developing acute symptoms requiring emergency surgery is probably less than 2% per year.` In this patients case, a letter from her provider indicates the patient underwent an upper endoscopy and did not undergo surgical intervention at that time.  As such, she did not meet the above definition of emergency medical condition, as the surgical procedure at issue was not performed on an immediate basis. Further, the submitted documentation does not demonstrate the patient was experiencing acute symptoms that necessitated immediate surgical intervention. Moreover, criteria for urgently needed services were not met in this case. Although the presence of impacted food was noted upon endoscopy, measures other than the disputed fundoplication procedure could have been utilized to prevent serious deterioration of the patients health until she was able to return to the her plans service area. Thus, the submitted documentation fails to establish that the services at issue were urgently needed. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for emergency care or urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. 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: 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:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis has been associated with a decrease in callbacks and an increase in detection of small cancers.  Per the medical literature, the addition of the technique is more likely of benefit to the patient than if the examination is done with two-dimensional imaging alone.  All told, breast tomosynthesis was likely to have been superior over other modalities. 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: 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. Per the guidelines, treatment-naive genotype 1 patients 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. AASLD 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus (HCV) genotype 2. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active 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. The proposed combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, Sovaldi and ribavirin for 12 weeks is medically necessary for treatment of the patients medical condition. 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: The parent of an enrollee has requested for occupational therapy, (with a portion being sensory integration therapy) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested therapy. According to the documentation submitted for review, the patient continues to require treatment for her fine motor skills. It is likely she will meet these goals soon. In addition, the patient also has sensory integration goals. Researchers examined the effectiveness of Ayres Sensory Integration (ASI) and sensory-based interventions within the scope of occupational therapy for patients with autism spectrum disorder to improve performance in daily life activities. They found that the ASI intervention had moderate level of good quality research to indicate this can be recommended for children with autism spectrum disorder. In addition, researchers also found that sensory integration interventions can improve daily living skill attainment. They also reported better engagement in the classroom with frequent physical activity breaks. Overall there is evidence that sensory based interventions are effective for helping children with autism spectrum disorder with self-regulation, tolerating noisy environments and improving oral motor sensory issues.  Although the patient has made improvements in many areas, she still has difficulty with sensory issues and she still requires occupational therapy, including sensory integration therapy. Based upon the documentation provided, the medical necessity for occupational therapy (with a portion being sensory integration therapy) has been established.  Final Result: The reviewer determined that the requested therapy 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 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 Harvoni for treatment of her medical condition.  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. Per guidelines, patients with diabetes are high priority for therapy.  The guidelines recommend that treatment-naive genotype 1 patients 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. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as 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.