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

Nature of Statutory Criteria/Case Summary: An enrollee is requesting Sovaldi for the treatment of his hepatitis C infection. 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, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage.  The guidelines do not recommend other regimens for ribavirin-eligible genotype 2 patients.  For these reasons, Sovaldi 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program level of behavioral health services for treatment of her behavioral health condition.   Findings:  The physician reviewer found that intensive outpatient services were not and are not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review the patient was not in withdrawals.  She was not a threat to herself or others. She was psychiatrically and medically stable. She had improved and was gaining skills towards her recovery. She no longer required the frequency or intensity of an IOP program and her treatment could have continued on an outpatient basis with concomitant community based support from a 12-step program. As such, intensive outpatient program level of behavioral health services was not and is not medically necessary. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Anser adalimumab (ADA) assay for evaluation of his medical condition.  Findings:  Two physician reviewers found that the Anser ADA assay was likely to be more effective for this patient than other available treatment options. In this case, Anser ADA was appropriate for the management of this patient who was being treated with medication, and was still symptomatic. The assay was done to assess the drug levels of ADA and to check the antibodies to ADA so that the appropriate decision could have been made by the treating physician in terms dose adjustment of his current medication, or switching to another biologic. Therapeutic drug monitoring is the clinical practice of measuring drug concentrations or metabolites to attain a targeted concentration in a patients bloodstream, thereby optimizing individual dosage regimens. Maximizing the efficacy of therapies for Crohns disease, while minimizing their toxicity remains the principal objective in developing management strategies for these patients. Recognition of the factors influencing therapeutic response allows clinicians to individualize dosing regimens to meet this objective. In order to optimize therapy, it is critical that providers understand that standard dosing is insufficient for most patients, given the interindividual variability relating to response and tolerability. Therefore, services at issue were appropriate for the management of the patients Crohns disease in order to optimize his therapy.   Final Result: Two reviewers determined that the services at issue were 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:  One reviewer is board certified in internal medicine with sub-specialty certifications in transplant hepatology and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 24 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), both of the regimens listed below are recommended for treatment-experienced genotype 1 patients with cirrhosis as a Class I, Level A rating. The patient is requesting daily fixed-dose combination of ledipasvir/sofosbuvir for 24 weeks is a recommended regimen for patients in whom prior peg-interferon and ribavirin treatment has failed. The Health Plan recommends the preferred therapy of daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir plus twice-daily dosed dasabuvir and weight-based ribavirin for 24 weeks is an alternative regimen for patients with compensated cirrhosis, in whom prior peg-interferon and ribavirin treatment has failed. Based on the documentation submitted for review, the patient is not ribavirin-ineligible, and can be treated with Viekira Pak plus ribavirin. As such, the medical necessity for Harvoni for 24 weeks has not been established 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 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 proton beam radiation therapy for treatment of his medical condition.  Findings:  Two physician reviewers found that proton beams have less scatter than other sources of energy such as gamma rays, x-rays, or electrons. Because of this feature, proton beam radiotherapy (PBRT) has been used to escalate radiation dose to diseased tissues while minimizing damage to adjacent normal tissues. Proton beam radiotherapy has been shown to be particularly useful in treating radiosensitive tumors that are located next to vital structures, where complete surgical excision or administration of adequate doses of conventional radiation is difficult or impossible. Because of these physical properties, it has been theorized that PBRT is especially useful for cancers located in areas of the body that are highly sensitive to radiation and/or where damage to healthy tissue would be an unacceptable risk to the patient.  As such, the proton beam radiation therapy at issue was likely to be more beneficial for treatment 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 treatment 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 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:  An enrollee has requested Praluent for treatment of his medical condition. Findings:  The physician reviewer found that PCSK9-inhibitors are a new class of medication that has been shown to reduce cardiovascular events when used in combination with statin medications. However, there is a lack of long-term data on the use of PCSK9 inhibitors and thus the potential for long-term adverse effects is unknown. Also, current guidelines do not recommend the addition of a PCSK9 inhibitor such as Praluent in the setting of LDL less than 100mg/dl while on statin therapy. Moreover, a recent trial has shown outcome improvement with Zetia added to a statin in this setting, a medication that does have longer term follow up with a proven safety profile compared to PCSK9 inhibitors. Overall, given the unknown long-term risks of PCSK9 inhibitors; the modest reduction in LDL required in this case; and the proven benefit with the addition of Zetia, the addition of Zetia is a preferred approach compared to the addition of Praluent. As such, based on available studies and the documentation provided, the use of Praluent is not medically necessary for treatment of this patients medical condition.   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 physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C. Findings:  The physician reviewer found that per 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 due to nonliver-related conditions. For treatment-experienced patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Oncotype DX gene expression test for evaluation of his medical condition.   Findings:  Two physician reviewers found that Oncotype DX assay is an assay of specific genes in an individuals cancer cells. It has become widely accepted as useful in the treatment decision with early breast cancer.  A similar assay has been developed for prostate cancer, in the hopes that the assay would allow the provider to determine if an individual had a prostate cancer that needed specific treatment, versus watchful waiting only. The technology has been validated as reliable.  However, it has not as yet been shown to enable a clinician to make a decision about treatment that is superior to that decision made by more conventional criteria, such as the age of the patient, Gleason grade, extent of the cancer, and prostate specific antigen.  He does not fulfill the criteria used to define low-risk, thus, he would be classified as intermediate risk.  There is a lack of reliable data demonstrating that making a treatment decision incorporating Oncotype DX gene expression testing is an improvement over a clinical criteria decision alone.  Therefore, Oncotype DX gene expression testing was not likely to have been of greater benefit than other modalities. Final Result: Two 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 reviewers are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ultraviolet B (UVB) (Dermalight 90 narrowband (NB)-UVB Light) for home use for treatment of his medical condition.  Findings:  Two physician reviewers found that the patient presents with chronic prurigo nodularis of the scalp, which has been complicated with secondary infection in the past. He has had this condition for several years. He has been treated with oral and topical antibiotics, antihistamines and corticosteroids. He has had some relief with the intralesional corticosteroids, but these are not generally considered long-term therapy due to side effects. He also had some relief when he was in a sunny location for a prolonged period. His provider recommends treatment with narrow band-ultraviolet B (NB-UVB). Thus, the patient has requested authorization and coverage for ultraviolet B (UVB) (Dermalight 90 NB-UVB Light) for home use. The Health Plan has denied this request as investigational. Pruritus and prurigo nodularis are very difficult diagnoses to treat, and there is no standard therapy. In fact, there is a lack of drugs approved by the U.S. Food and Drug Administration for use in prurigo nodularis. The standard of care for treatment in this clinical setting has been tried. The use of NB-UVB is a common modality used to treat prurigo nodularis. One advantage to NB-UVB is the low systemic risk. It would be reasonable for this patient who has tried and failed multiple modalities to be treated with NB-UVB. Moreover, other treatments options could pose more systemic risk and would require some monitoring of other organs. Given the above, the requested device has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested device is 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:  All three reviewers are board certified in dermatology 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 OxyContin time release and Fentanyl transdermal patch for treatment of her chronic leg pain and low back pain.  Findings:  The physician reviewer found that the record reflects that the patient is diagnosed with multiple sclerosis (MS) and as such, the pain complaints related to this diagnosis falls under palliative medicine. The step wise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. According to the submitted records, the first step in the WHO ladder has not been documented. The records do not reflect that non-opioid treatment options have been utilized and failed. Also, the treatment plan for this patient does not show that she has tried other non-pure mu-agonist drugs that have long lasting duration. Furthermore, the available research indicates the importance of utilizing interventional treatment plans for patients with chronic pain who may be at risk for opioid misuse. Treatment plans should closely monitor new increases in medications. The available literature also recommends specific behavioral treatment plans designed to improve adherence with prescription opioids among persons treated for chronic pain. Finally, ample research shows how symptoms of MS should be treated. According to the records, the patient is on medication for her MS with fair to stable results. The patient noted that she has not experienced any new changes regarding her MS symptoms. But aside from medication, the documents provided do not discuss if standard MS treatments, both pharmacological and physical, have been performed and failed for this patient. Consideration of other management options for the patients MS may help improve her chronic pain symptoms. For the above stated reasons, the requested OxyContin time release and Fentanyl transdermal patch are not medically necessary for treatment of the patients medical condition.  Final Result: The 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: Physician reviewer number three is board certified in anesthesiology with sub-specialty certification in pain management 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 Supartz injections for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. This has been found to be safe and effective and allowed for delay of total knee replacement. There is a lack of evidence that one brand of hyaluronic acid is better than any other brand. This patient has been diagnosed with knee osteoarthritis and reports long-term use of Supartz injection series with good pain reduction. Therefore, the requested Supartz injections are medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee is requesting Harvoni for the treatment of his hepatitis C infection. 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.  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.  For these reasons, the requested Harvoni 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 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.