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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 12 weeks and possibly up to 24 weeks for treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that the medical necessity for treatment with sofosbuvir (Sovaldi) and daclatasvir (Daklinza) has not been demonstrated in this patients case. First, the proposed regimen is not FDA-approved for the patients indication, whereas the sofosbuvir and ribavirin regimen is both FDA-approved and carries a higher the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) rating. Moreover, the patient has not demonstrated intolerance to ribavirin. Per FDA labeling, sofosbuvir and ribavirin can be safely used in the patients situation if fertility is avoided during and for six months after his treatment course (a duration no longer than 10 months). For the reasons provided, Sovaldi and Daklinza for 12 weeks and possibly up to 24 weeks is not medically necessary in this clinical setting.  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 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 proton beam radiation therapy for treatment of her acoustic neuroma.  Findings:  Three physician reviewers found that currently, there is inadequate clinical data to support treatment with proton beam radiation as superior to conventional radiation therapy techniques in the treatment of this patients benign tumor. The data regarding central nervous system tumors treated with proton therapy is limited. There is a lack of evidence in this setting that proton beam therapy is associated with improved control rates, a decrease in toxicity or a decrease in secondary malignancies compared to conventional fractionated radiation therapy or radiosurgery techniques. One review noted concern that proton therapy may be associated with higher rates of hearing loss than standard photon techniques. Standard treatment is with photon techniques which are already associated with very high rates of local control and minimal toxicity. All told, the requested proton beam radiation therapy is not likely to provide this patient with greater health benefits than standard radiation therapy. 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential mental health treatment services for treatment of the enrollees major depressive disorder. Findings:  The physician reviewer found that after a detailed and intensive review, the patient does not meet the medical necessity criteria for admission and continued care at the residential treatment facility level of care. The patient has not previously been treated in a less restrictive level of care, is not psychotic, and the patient is able to take care of himself. Thus, although the patient does need mental health services, treatment at the residential level is not medically necessary. The multidisciplinary intensive outpatient program (IOP) level treatment is less restrictive and is likely to be more efficient and effective. For these reasons, the residential mental health treatment services provided were not and are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewers 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested air and ground ambulance services for treatment of his medical condition. Findings:  The physician reviewer found that air ambulance services are considered medically necessary when specific criteria are met.  Specifically, the air ambulance must have the necessary equipment, the patients condition must be such that transportation other than by air ambulance is medically contraindicated, the patients condition is such that transport by land poses a serious threat to the patients survival, the patient is transported to the nearest hospital with appropriate facilities for treatment, and there is a medical condition that is life-threatening.  The use of air ambulance services to transport a patient from one hospital to another may be indicated if the first hospital does not have the required facilities to treat the patient.  Air ambulance services are not considered medically necessary when the transfer is from one hospital capable of treating the patient to another hospital for the convenience of the patient or patients family, or when the transport is to a hospital other than the nearest one with appropriate facilities.  Although a letter from the provider indicates transfer to the facility in another state was for the best possible outcome, there is a lack of objective evidence in the medical record that one spinal cord rehabilitation facility is more qualified than the other in treating patients with spinal cord injury.  The medical records indicate that the spinal cord injury treatment center from which the patient was transferred was appropriate for this patients level of care. There is no medical justification for transfer to a different spinal cord injury center.  All told, air and ground ambulance services provided were 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her 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), 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 AASLD/IDSA guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Noncirrhotic patients with viral load below 6 million IU/mL can be treated with Harvoni for eight 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 also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for eight 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.
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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. This patients case illustrates one of the important values of digital breast tomosynthesis in that the technique often allows the radiologist to subtract out dense glandular elements of the breast from underlying architectural distortion which in turn could reflect an early infiltrating cancer. The advantage is due to the tomographic nature of digital breast tomosynthesis.  Sometimes, as in this case the appearance of the breast on tomosynthesis alleviates the need for ultrasound as a separate examination. Therefore, the breast tomosynthesis was likely more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 skilled nursing facility treatment services for treatment of the enrollees traumatic brain injury.  Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility treatment services has been established. In this case, the patient has severe brain injury and is in a vegetative state. Skilled nursing level care is for patients who are undergoing rehabilitation and have nursing needs. In this case, the patient has nursing needs. The patient requires monitoring in a facility with continuous pulse oximetry and registered nurses present. For the reasons provided, continued skilled nursing facility treatment services are medically necessary for treatment of the patients medical 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 physical medicine and rehabilitation and neuromuscular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her overactive bladder.  Findings:  Three physician reviewers found that based on the current peer-reviewed medical literature, PTNS is an appropriate and indicated third-line treatment option for patients with overactive bladder. In this case, standard, proven first-line and second-line treatments have not reportedly been used prior to resorting to PTNS, which is reserved for patients who have failed treatment with standard therapies. Given these findings, the PTNS treatment was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not and 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 urology 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 three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Two physician reviewers found that there is a lack of evidence in the peer-reviewed literature that supports the use of breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising technology, there is a lack of peer-reviewed literature supporting its use in this clinical setting. As such, the services at issue were not likely to be more beneficial than standard modalities. Final Result: Two reviewers determined that the diagnostic procedure at issue was 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 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 skilled nursing services for the treatment of her medical condition.  Findings:   The physician reviewer found that there is limited high-grade evidence guiding the optimal rehabilitation strategies following distal radial fractures and ankle/foot fractures.  The patient has been placed on non-weight-bearing restrictions for one upper limb and the contralateral lower limb due to her recent left distal radial and right foot fractures.  She has made some progress with respect to self-care abilities, but has plateaued at requiring some assistance for her lower body self-care and transfers.  She has remained non-ambulatory.  There are no indications that she has been self-propelling a wheelchair.  There is no indication that caregiver training has taken place.  There is a lack of support for the services at issue in this clinical setting.  All told, skilled nursing services are 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 physical medicine and rehabilitation 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 her 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 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, non-cirrhotic genotype 1 patients who have failed therapy with interferon and ribavirin should be re-treated with Harvoni for 12 weeks.  All told, the requested Harvoni for 12 weeks is medically indicated for the treatment of this patient.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 eight weeks for treatment of his hepatitis C. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patients records do not support advanced fibrosis.  However, American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines support treatment irrespective of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months.  There is sufficient support for the requested medication in this clinical setting.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient. 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.  The addition of breast tomosynthesis to screening mammography has gained popularity due to an associated decrease in callbacks and increase in detection of small cancers.  This improvement is due to the tomographic nature of tomosynthesis which allows separation of overlying glandular tissue from underlying mass or architectural distortion.  Thus, the addition of breast tomosynthesis was likely to be of greater benefit to the patient than two-dimensional mammography without tomosynthesis. 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: An enrollee has requested Prolia injections bimonthly for treatment of her osteoporosis and pancreatic cancer.  The physician reviewer found that Prolia is approved by the U.S. Food and Drug Administration (FDA) and is indicated for treatment of women with postmenopausal osteoporosis who are at high risk of fracture.  The Xgeva label also states that it is indicated for prevention of skeletal events in patients with solid tumor bony metastases. This patient has no evidence of bone metastases from her pancreatic cancer. There is however evidence for osteoporosis based on her T-score of -2.61, which confers a high risk of fracture. This level of osteopenia meets the standard cut-off at which point pharmacologic therapy is indicated. Thus, the use of Prolia in this patient is consistent with the FDA label and with standards of care for osteoporosis. In addition, Prolias prescribing information for dosage and administration states administer 60 mg every six months as a subcutaneous injection. Thus, Prolia every two months is not indicated. In sum, the Prolia injections every six months were and are medically necessary. Final Result: The reviewer determined that a portion of the services at issue were and 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 oncology and hematology 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.