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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Botox injections for treatment of her medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature supports the use of Botox injections in this clinical setting. The records submitted for review document the patient has daily migraine headaches that have been refractory to standard therapies. In addition, she has had a positive response to Botox in the past. Thus, a trial of Botox is clinically indicated. The literature cited above supports the use of Botox for chronic headache patients. In addition, undertreated headaches can cause unnecessary significant morbidity to a patient.  For the reasons provided, Botox injections are 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 services 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:   All three reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of his hepatitis C virus.   Findings:  The physician reviewer found that Sovaldi has been approved by the U.S. Food and Drug Administration for patients with chronic hepatitis C genotype 2. Pursuant to 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. The guideline recommendation for treatment-naive genotype 2 patients is Sovaldi and ribavirin for 12 weeks. Multiple randomized clinical trials support the use of Sovaldi in this setting (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. As such, the requested Sovaldi 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Concerta (methylphenidate) for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested medication is not medically necessary for treatment of the patients behavioral health conditions. The patient is currently receiving methylphenidate ER 36 mg, which is the generic form of Concerta. One of the formulary alternatives is methylphenidate sustained-release tablets, or generic Ritalin SR. The active ingredient of both these medications is methylphenidate.  The only difference between the two is the delivery system to make the medication extended release. In the case of the patients current medication, an osmotic delivery system is used. A different mechanism would be utilized for the proposed alternative medication. Switching from the current medication to another methylphenidate extended release is not likely to be difficult. Most likely, the patient could take 40 mg of the new medication instead of the current 36 mg and have a fairly similar medication effect. It should only take one or at most two visits to titrate to the effective dosage. In addition, the school year is almost over, so the timing would be appropriate to make the switch. Given the above, the requested medication is not medically necessary for treatment of the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) for evaluation of his medical condition. Findings:  Two physician reviewers found that the medical evidence does not support the requested services in this patients case.  The medical records demonstrate moderately active rheumatoid arthritis.  X-rays of hands and feet show a single erosion.  The plan is to continue methotrexate and consider starting an anti-tumor necrosis factor agent.  The x-rays show evidence of erosive disease.  It is unclear from the record how an MRI would impact the patients treatment.  Thus, the requested MRI is not likely to be more effective than other modalities for evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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 rheumatology 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 hospital stay for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, initial inpatient level of care was not medically necessary as the patient was being treated in the emergency department during this time. The patient presented with headache and neurologic deficits on exam.  The concern was for an infectious etiology given the abnormal lumbar puncture and cerebral spinal fluid results.  According to medical literature cited above, empiric treatment for herpes simplex virus (HSV-1) infection with acyclovir IV should always be initiated as soon as possible if the patient has encephalitis without apparent explanation. Early therapy is vital because it is associated with a significant decrease in mortality and morbidity. The recommendation is for treatment with IV acyclovir, and oral treatment should not be used. The IV acyclovir should continue until the results of the testing confirm that the patient does not have HSV encephalitis. In this case the patient presentation was concerning for a viral encephalitis.  Empiric treatment with IV acyclovir was medically necessary until laboratory tests confirmed that the patient did not have HSV infection.  Thus, a subsequent hospital stay was medically necessary. All told, a portion of the services at issue were medically necessary for treatment of the patients medical condition. 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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her breast cancer screening.  Findings:  Two physician reviewers found that in this patient, the breast tomosynthesis portion of the exam was more beneficial as compared to standard 2D mammogram in screening for breast cancer. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. There is sufficient evidence supporting the use of tomosynthesis for routine breast cancer screening. Thus, breast tomosynthesis was likely to be more beneficial than any available standard modalities.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested power wheelchair. In this case, the patient is an independent ambulator. The records do not demonstrate that the patient would be bed or chair confined without a power mobility device.  There are no impairments that would preclude the patient from using a knee walker or propelling a manual wheelchair. The patient does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude him from using an optimally configured manual wheelchair to accomplish his mobility-related activities of daily living. Any mild strength deficits can be addressed with exercise and strengthening. Moreover, physical activity is highly appropriate and recommended for persons with conditions such as diabetes, hypertension and for general musculoskeletal health (Hagen, et al). Moreover, manual wheelchair use has been shown to provide significant health benefits use over power wheelchair use for persons with mobility impairments (Keyser, et al; Hastings, et al). Therefore, based on the clinical documentation submitted, the power wheelchair is not medically necessary for treatment of the patients medical condition. 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 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 ketamine injections for treatment of his medical condition.  Findings:  Two physician reviewers found that current medical evidence does not support the services at issue in this patients case.  There are many unknowns regarding the antidepressant effect of ketamine, not to mention its risk of treatment-induced hypomania or full-blown mania for those with bipolar disorder.  There is a lack of evidence-informed practice guidelines regarding pre-treatment screening and patient selection criteria, intra-treatment recommended observational metrics, dosing schedules and treatment duration, and post-treatment follow-up.  Finally, the medical documentation does not support the services at issue.  The patient was described as a partial responder to pharmacotherapy.  Previously, he was improved with less anger and irritability.  He reported good benefit from his medications on another occasion.  Further, it does not appear that previously helpful interventions had been exhausted during the episode of illness.  The patient had a therapist, but it is unclear if he had engaged specific evidence-based interventions for bipolar illness, such as cognitive behavioral therapy, family therapy, interpersonal and social rhythm therapy.  All told, ketamine injections were not likely to have been superior over other treatment options.  Final Result: Two reviewers determined that the services at issue were 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 psychiatry and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that while this patients record may not support advanced fibrosis, the medical necessity of HCV treatment, as per AASLD/IDSA recommendations, and the medical appropriateness of therapy as proposed for this patient, exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  The patients record indicates that his life expectancy exceeds this limit. Based upon the recommendations stated above, the requested Harvoni is medically necessary for treatment of the patients HCV 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 physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. AASLD/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 physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings: The physician reviewer found that pursuant to guidelines set forth 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. Per the guideline recommendations, treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Furthermore, Harvoni 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 treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C virus.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases 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.  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.  All told, 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 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 a wearable external defibrillator for treatment of her medical condition.   Findings: Three physician reviewers found that in this circumstance, there is potential for recovery of left ventricular function over time with therapy and there was no indication for immediate placement of a defibrillator such as documented sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time (>90 days) where continued left ventricular dysfunction (ejection fraction  35%) is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. At this time prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed, such as due to infection or required explanation. Therefore, in this circumstance the request for a wearable external defibrillator has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested services are 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 cardiovascular diseases 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.