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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for six months for treatment of her chronic hepatitis C virus genotype 3a.  Findings:  Three physician reviewers found that as 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. The goal of treatment of hepatitis C virus infected persons is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Thus, the requested Sovaldi and ribavirin for six months are medically necessary for treatment of this patients chronic hepatitis C virus infection. Final Result: Three reviewers determined that the requested medications are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: 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 six months of intravenous immunoglobulin (IVIG) therapy, or Rituxan infusions for treatment of her vasculitis and vasculitic neuropathy. The physician reviewer found that for the treatment of vasculitic neuropathy, the use of immunosuppressive agents is based on case reports or patient series. Most review articles use corticosteroids alone or in combination with cyclophosphamide, azathioprine or methotrexate. Most of the larger studies have used azathioprine in their patients with good responses. In this case, this patients records, clinical findings, and laboratory results do not support a diagnosis of vasculitic neuropathy. This patient has previously been treated with Imuran as well as oral and intravenous Cytoxan. However, the records do not document that the patient has been treated with the standard of care regimen consisting of high dose prednisone with or without cyclophosphamide. The medical records also do not demonstrate that the patient has tried or has a contraindication to treatment with corticosteroids or methotrexate. Her evaluation fails to demonstrate a systemic vasculitis or a primary rheumatological disorder causing her vasculitic neuropathy. As there is only evidence of improvement in primary systemic vasculitis and not peripheral vasculitis, the requested IVIG is not indicated. Should the patient not respond to prednisone, or continues to require long-term therapy, then either IVIG or Rituxan would be medically necessary. However, given the lack of documentation supporting an indication for IVIG or Rituxan, the requested therapies are not supported as medically necessary. Final Result: The reviewer determined that the requested therapies 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, rheumatology, and allergy and immunology 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 residential treatment for treatment of her behavioral health conditions. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Upon presentation, the patient was at a healthy weight.  Her body mass index was within normal limits.  Her vital signs were stable, and she did not have any orthostatic changes.  There was no mention of laboratory abnormalities at the time, and her electrocardiogram was reported to show a normal sinus rhythm.  The following day, the patient was described as motivated for treatment during her first psychotherapy session.  Thereafter, the patient did demonstrate situationally appropriate emotionality largely related to relationships and wariness of relapse, but did not have any difficulty with the therapeutic programming.  Further, during the episode of illness which prompted referral by her psychiatrist, it does not appear that the patient failed a comprehensive eating disorder treatment program, including dietary education, nutritional counseling, family therapy, group therapy, cognitive behavioral therapy and/or interpersonal therapy, delivered in an intermediary setting such as an intensive outpatient or partial hospital program.  This is particularly important in this case as there was no evidence that specialty services provided in a less restrictive setting would have been inappropriate or unsuccessful based on the patients motivation, health and support system.  Finally, considering the patients psychiatric stability, the quest for diagnostic clarification did not require the residential setting to be safely accomplished.  In sum, residential treatment as not and is not medically necessary 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 substance use residential treatment center for treatment of his behavioral health conditions.  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  In this case, the patients illness burden had resulted in psychiatric sequelae and marital distress.  He did not have a supportive home or a meaningful sober network of social support at the time.  His self-proclaimed motivation for sobriety was inconsistent with his behaviors.  Following a residential stay earlier, he was unable to maintain sobriety with outpatient and community services.  Upon presentation, the patient had a mild withdrawal syndrome.  Further, he had multiple co-occurring chronic psychiatric conditions which compromised his prognosis.  Finally, the severity of the patients drug use represented a significant factor.  The patients drug use dominated his daily routine, and negatively impacted his relationships and caused significant impairment across multiple domains of functionality. All told, substance use residential treatment center services were medically necessary initially, but not subsequent to that time.   Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.   Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 peer-reviewed literature that supports the use of 3D breast tomosynthesis compared to currently available techniques, especially in a patient without a personal or family history of breast cancer. Although breast tomosynthesis may be a promising technique, its clinical efficacy is yet to be substantiated in the peer-reviewed literature. Therefore, 3D breast tomosynthesis was not likely to be more beneficial than other 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 Sovaldi and ribavirin for 24 weeks for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases, for retreatment of patients with genotype 2 who previously failed therapy with sofosbuvir plus ribavirin, the recommended regimen is either daclatasvir plus sofosbuvir (with or without ribavirin) for 24 weeks or sofosbuvir plus ribavirin plus peginterferon for 12 weeks. Currently, the combination of daclatasvir plus sofosbuvir has not been approved by the U.S. Food and Drug Administration (FDA) for genotype 2 patients. The use of Sovaldi and ribavirin for 24 weeks in patients who have previously failed Sovaldi and ribavirin for 12 weeks is not supported by clinical studies. As such, the request for Sovaldi and ribavirin for 24 weeks is not medically indicated for treatment of the patients hepatitis C, genotype 2a.  Final Result:  Three reviewers 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: 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: 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.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  In this patients case, Harvoni for 12 weeks is likely to prevent further damage of the liver and disease progression.  Per the guidelines of the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated 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.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program (IOP) services for treatment of her panic disorder with agoraphobia and obsessive compulsive disorder (OCD).   The physician reviewer found that this patient evidenced dramatic symptoms of anxiety and affective illness with elements of character pathology. Her formidable symptom burden, which had required treatment in more restrictive settings and had not responded to outpatient services and was complicated by relationship distress and obesity. As such, a conservative treatment course was to be expected. However, based on the medical records, treatment at the IOP of care was only necessary initially.  The patient remained depressed, withdrawn and anxious. She struggled with identity issues and was having difficulty with cognitive restructuring. The patient continued with clinical interventions delivered in accordance with a treatment plan that were reasonably expected to improve her condition and prevent a more serious episode of illness. Further, the IOP services helped clarify diagnoses as evidence for borderline personality disorder emerged during the disputed treatment course and eventually prompted redirection of the therapeutic interventions. Subsequently, the patients lability, attachment issues and treatment needs no longer required treatment at the IOP level of care. Thus, the IOP services initially were medically necessary, but subsequent services were not medically necessary. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers 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 less than 12 months due to non-liver-related comorbid conditions.  Patients with cirrhosis are considered highest priority for therapy.  Harvoni for 12 weeks is recommended for cirrhotic, treatment-naive patients with hepatitis C, genotype 1 infection.  Based on the medical literature and clinical guidelines, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Three 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: 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:  The parent of an enrollee has requested residential treatment center level of care services for treatment of the enrollees behavioral health condition. The physician reviewer found that the residential treatment center level of care services were not and are not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, this patient does not meet the criteria for admission to substance abuse residential treatment level of care and the services in dispute could have been provided at a lower level of care. There was no documentation of serious mental illness that would have complicated substance abuse treatment at a lower level of care. He also had no pre-existing medical problems that could have caused withdrawal complications and he had no past history of serious withdrawal complications. He was not at imminent risk of harm to self or others due to mental illness or substance abuse. He had access to safe supportive environments that would have allowed treatment at a lower level of care. Based on the medical literature cited above and the documentation submitted for review, the services at issue were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Otezla for treatment of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient is currently followed for a diagnosis of inflammatory bowel disease associated arthritis with a possible diagnosis of psoriasis.  The available medical records do not contain adequate documentation that establishes a diagnosis of plaque psoriasis or a diagnosis of psoriatic arthritis.  On the basis of the available medical documentation and per the current recommendations for use of this medication, the requested Otezla  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 internal medicine with sub-specialty certification in rheumatology 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 occupational therapy for treatment of the enrollees autism spectrum disorder.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. While the literature indicates occupational therapy can help improve fine motor skills, in this case, the patient presents with sufficient fine motor skills per PDMS testing. The patients primary deficits involve issues of self-regulation and following adult directions which are symptoms of autism. As such, the Health Plans recommendation that the patient collaborate with the patients ABA provider is medically reasonable and appropriate to address his adaptive skills, social skills and self-regulation. Based upon the documentation provided, the medical necessity of occupational therapy has not been established.  Final Result: The reviewer determined that the requested services 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 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 a 12 week course of Harvoni for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that denying treatment for a chronic disease such as HCV because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. Harvoni is a one-pill drug that is used without ribavirin and has no serious adverse effects or contraindications. The U.S. Food and Drug Administrations approved use includes patients with early stage disease. In addition, treatment delays may decrease the benefit of sustained virologic response. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. In addition, national joint guidelines recommend Harvoni for 12 weeks for treatment-experienced chronic HCV patients with genotype 1a. Therefore, the request for Harvoni for 12 weeks is medically necessary for this patient. 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 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.