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 Provigil for treatment of the enrollees post-concussive syndrome.  The physician reviewer found that Provigil is a wake promoting agent that has been approved by the U.S. Food and Drug Administration (FDA) for narcolepsy, obstructive sleep apnea, and shift work sleep disorder. Provigil is currently not approved for children under 18 for any indication. In addition, Provigil has been studied as a treatment for fatigue or excessive sleepiness in a variety of other disorders, such as multiple sclerosis, Parkinsons disease, brain injury and attention deficit hyperactivity disorder (ADHD). Although there are some studies which show that Provigil may be beneficial in treating fatigue or excessive sleepiness associated with traumatic brain injury, these studies are not sufficient to support Provigil as medically necessary for the treatment of this patients condition. In addition, there is a lack of studies which evaluate Provigil for the treatment of sleepiness in children after brain injury. Based on a lack of available data regarding the efficacy and safety of Provigil for the treatment of fatigue or sleepiness, especially in children, Provigil was not and is not medically necessary for this patients condition. Final Result: The reviewer determined that the medication at issue was not and 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 pediatric 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 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Guidelines further state that 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. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. In this case, the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV genotype 1. Moreover, the requested treatment is expected to prevent further damage of the liver and progression of the disease process and its potential complications. All told, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients medical condition. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition. that
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a food allergy test for evaluation of her irritable bowel syndrome.   Three physician reviewers found that there is a lack of support for food allergy testing in the medical literature. Food allergy testing typically includes food-specific immunoglobulin G (IgG) and IgG4 tests (such as the Genova lab profile), which typically yield multiple positive results and may represent a normal immune response to food. Food-specific IgG4 does not predict true food hypersensitivity, and may actually be a marker of earlier development of tolerance. In sum, there is no role for the use of allergy testing to guide the treatment of IBS. For the reasons provided, food allergy testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a bone growth stimulator for treatment of his medical condition.  Three physician reviewers found that there is a lack of peer-reviewed literature evidencing long-term safety and efficacy of the device at issue in this clinical setting.  Randomized controlled studies on a larger scale are needed to validate the current evidence and generate more specific clinical guidelines.  There is a need for large and definitive trials that use patient-important outcomes.  Most literature supports rest as the most important treatment in the acute phase of a tibial stress fracture.  Patients may require relative rest and cessation of sport for prolonged periods of time, depending on the severity of their symptoms.  Cryotherapy is also commonly used in the acute period.  All told, the superior efficacy of the device at issue has not been established. Final Result: Three reviewers determined that the device at issue was not and 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 orthopedic surgery 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 eight weeks for treatment of her hepatitis C virus.  Findings:  Two physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients, therapy is recommended with Harvoni as a Class I, Level A recommendation. 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. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni should be considered medically necessary for eight weeks in this case. Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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 a fitted shoe (orthotic boot) for treatment of his osteoarthritis of the left ankle.  The physician reviewer found that a review of the literature reveals that for well selected patients, normal footwear is all that is needed following ankle fusion. However, articles also discuss several different types of shoe modifications, in-shoe orthoses, and ankle foot orthoses that are very commonly used for many patients following this procedure. Sirveaux and colleagues reported that modifying shoegear to increase the instep of the shoe improves the biomechanical abnormalities that occur. After a complete review of the patients medical record, as well as the current medical literature, a shoe modification and possibly an in-shoe orthotic or an ankle-foot orthotic is medically necessary for treatment of this patients medical condition status post ankle fusion. The patient sustained an open talar fracture, which later went on to an ankle fusion. One known sequelae of traumatic injury going on to ankle fusion is limb length discrepancy. For this reason, an evaluation of this problem and a shoe modification to address it is medically necessary. In conclusion, a specially modified shoe, with or without an in-shoe orthotic, or an ankle-foot orthosis, is medically necessary. Final Result: The reviewer determined that the requested equipment 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 podiatry 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.  Findings:  The physician reviewer found that
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sofosbuvir and daclatasvir for treatment of his hepatitis C.  Two physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Urgent initiation of treatment is recommended for some patients, such as those with advanced fibrosis or compensated cirrhosis.  This patient has failed previous interferon-based treatment and later failed sofosbuvir and ribavirin.  The current medical evidence supports the requested treatment regimen of sofosbuvir and daclatasvir in this clinical setting.  In this patients case, urgent initiation of treatment is indicated, as he has an extrahepatic manifestation of hepatitis C, namely large B-cell non-Hodgkins lymphoma.  All told, sofosbuvir and daclatasvir is medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 40 hours per week of applied behavioral analysis (ABA) therapy and five (5) hours per week of supervision for treatment of the enrollees autism spectrum disorder.   Three reviewers found thatABA is a behavioral approach with a longstanding history of application with children on the autistic spectrum. ABA programming utilizes scientifically validated methods that are incorporated into a comprehensive individualized plan for the child with autism. In one study, comparing children who received intensive behavioral treatment to those who received a more eclectic treatment modality, the behavioral treatment group exhibited larger increases in IQ and adaptive functioning, as well as less aberrant behaviors and social problems, than did the other group. ABA therapy is effective when used intensively, approximately 40 hours per week, to comprehensively address all challenges experienced by children on the spectrum. Less exposure to the prescribed methods is inadequate to provide the necessary structure and intervention. In the case of this patient, she requires intensive one-to-one intervention and supervision to elicit desired responses and promote desired changes in behavior. Thus, based on the current literature as well as plan definitions, the recommended ABA therapy and five (5) hours per week of supervision was and is medically necessary. Final Result: Three reviewers 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:  One reviewer is board certified in pediatrics and pediatric critical care and is actively practicing. Two reviewers are board certified in pediatrics and pediatric neurology and are actively practicing.  All three reviewers are 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 Trulicity and Vascepa for treatment of his hypercholesterolemia and diabetes mellitus.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  The records document diabetes and hypertriglyceridemia.  In this circumstance, treatment with lifestyle changes and medication is appropriate and recommended by current guidelines.  The patient has requested coverage for Vascepa.  However, the Health Plan denied this requested due to an inadequate trial with two of the following medications: gemfibrozil (Lopid), micronized fenofibrate or Niacin.  These alternative medications are effective in the treatment of hypertriglyceridemia, and it is medically appropriate to try these drugs prior to Vascepa.  Glucagon-like peptide-1 (GLP-1) agonists such as Trulicity are not first-line agents to treat diabetes, are relatively new drugs, and the long-term risks and benefits of these agents are not known.  In this patients case, there is a lack of support for Trulicity over other medications in this class. Therefore, the use of Trulicity over another medication in this class, such as Bydureon, is not medically necessary.  All told, Trulicity and Vascepa are not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medications 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 internal medicine with sub-specialty certification in cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a power wheelchair for treatment her severe cervical stenosis at C4-7.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. Edwards and Mccluskey state The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. In this case, the patient has had impaired functional mobility for which she has been at a skilled nursing facility for over one year. A manual wheelchair allows mobility in her room. However, there are no medical notes documenting a rationale for a power wheelchair. In addition, the patient resides in a facility where assistance is available and additional surgeries/treatments are possible to improve her mobility status. As such, there is a lack of support in the documentation submitted for review establishing the medical necessity for a power mobility device at this time. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. All told, the medical literature supports the requested Viekira Pak as medically necessary for treatment of this patients medical condition. Final Result:  Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Ribapak for 24 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated with antiviral therapy regardless of fibrosis score. The guidelines note that the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The guidelines recommend daily Sovaldi and weight-based ribavirin for 12 weeks for treatment-naive and treatment-experienced patients with hepatitis C, genotype 2 infection. Consistent with current guidelines, a 12-week course of Sovaldi and Ribapak is medically necessary for treatment of the patients medical condition.   Final Result: Two reviewers determined that Sovaldi and Ribapak for 12 weeks is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications:  The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C.  Findings:  Two physician reviewers found that per the medical evidence, hepatitis C direct antiviral therapy should be prioritized for patients who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America.  The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis or compensated fibrosis and those with severe extrahepatic manifestations of hepatitis C infection, such as leukocytoclastic vasculitis.  High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis or coexisting liver disease.  Based on the presented clinical information, the patient does not meet priority considerations for treatment.  All told, the requested Sovaldi and ribavirin for 24 weeks are not medically indicated for the treatment of this patient. Final Result: Two reviewers determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.