Persius/hicric huggingface dataset:
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 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.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for her breast examination. Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast. In this particular patient, she was noted to have heterogeneously dense breasts. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. This technology has the potential to change conventional mammographic screening and diagnostic imaging with improvements in cancer detection, decreased call backs, and fewer false positive biopsies. For these reasons,  breast tomosynthesis was likely to be more beneficial for the evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was likely more beneficial for evaluation 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 radiology and is actively practicing. Two reviewers are board certified in radiology with sub-specialty certification in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a Krabat Jockey Plus Chair for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested equipment.  This patient has a progressive neurodegenerative disorder characterized by extrapyramidal movement abnormalities, spasticity, cerebellar ataxia, and epilepsy.  It affects strength and coordination, with development of severe dystonia, progressive spasticity, choreoathetosis, ataxia, and rigidity.  It impacts speech and ability to chew and swallow effectively, resulting in dysarthria or anarthria.  This patient requires specialized equipment in order to participate in activities of daily living while minimizing risk of complications. Without adequate support, severe spasticity and poor extremity control prevent him from remaining in proper positioning while sitting.  His condition necessitates specialized equipment to allow for social and therapeutic interactions, optimize functional capacity, and facilitate transition to older childhood and young adulthood.  This chair is designed for dynamic seating to allow for safe feeding, safe positioning for transfers, and for mobility. It has tremendous ability to adjust with the patients positioning needs, and is quite versatile, allowing for dynamic seating and balance control. It allows for social interactions and optimizes patient independence, particularly important for children with physical disabilities that severely limit or mask their cognitive development.  All told, the requested Krabat Jockey Plus Chair is medically indicated for the treatment of this patient.    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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza to be used in conjunction with Sovaldi for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) 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. Guidelines further state that The goal of treatment of HCV-infected persons 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 a sustained virologic response. In this case, the patient has F2 fibrosis, and delaying treatment would result in further progression of fibrosis. Per AASLD guidelines, daily sofosbuvir and ribavirin plus weekly peg-interferon for 12 weeks is recommended for peg-interferon eligible treatment-naive patients with HCV genotype 3 infection, as a Class I, Level A rating. In addition, daily daclatasvir and sofosbuvir for 12 weeks (no cirrhosis) or 24 weeks with or without ribavirin (cirrhosis) is recommended for treatment-naive patients with HCV genotype 3 infection who are peg-interferon-ineligible/intolerant, as a Class I, Level A rating. Based on the documentation submitted for review, the patient does not have a contraindication to interferon. The patient has mild thrombocytopenia with a platelet count which does not make him ineligible to interferon-based regimen. All told, the request for Daklinza (daclatasvir) to be used in conjunction with Sovaldi for 12 weeks has not been established as medically necessary in this clinical setting.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: Physician 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:   An enrollee has requested morphine concentrate (Roxanol) for treatment of her medical condition. Findings:  The physician reviewer found that morphine concentrate (Roxanol) is not medically necessary for treatment of the patients medical condition. The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Researchers reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. In sum, Roxanol is not clinically indicated 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 physician reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Xanax for treatment of her behavioral health condition.  Findings:  The physician reviewer found that Xanax (alprazolam) is not medically necessary for this patient. Alprazolam is a short-acting, highly lipophilic benzodiazepine, which means it has a rapid onset of action with a short duration of clinical effect. Studies have shown that alprazolam is highly addictive and potentially dangerous for patients. In 2011, there were 123,000 emergency room visits due to alprazolam misuse, 81% of which were in combination with alcohol or other prescription drugs. In this particular case, the patients records show that she has been non-adherent with treatment recommendations.  Further, the submitted records do not indicate that the patient has failed standard therapies used to treat anxiety and chronic pain, such as cognitive behavioral therapy, mindfulness and serotonergic enhancing medication. Accordingly, the requested Xanax is not medically necessary for treatment of the patients behavioral health 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 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 Norco for treatment of her medical condition.  Findings:  The physician reviewer found that the medical necessity of Norco is not established. The patient presents with non-malignant chronic pain which will often worsen or recur as a result of opioid rebound. The long-term use of high-dose short-acting opiates such as Norco has been shown to result in induced tolerance and abnormal pain sensitivity. Based upon the submitted records, the patient has a history of opioid treatment without documentation of improved function or attempted weaning.  Therefore, the requested Norco 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a threat to herself or others. She was medically stable. Although continuing to experience anxiety, her medication management did not require residential level of care. She was compliant with her treatment and meal plan.  She was learning communication skills and to identify triggers.  She did continue to demonstrate eating disorder behaviors.  However, she had improved and her treatment could have continued at a lower level of care.  All told, residential treatment center services were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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 a 12-week course of Sovaldi and Daklinza for treatment of her hepatitis C.  Findings:  The physician reviewer found that according to 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.  Patients with cirrhosis are considered to be highest priority for therapy.  The patient is interferon-ineligible due to a pre-existing condition.  In cirrhotic, treatment-naive, genotype 3 patients, therapy is recommended with Sovaldi and Daklinza (daclatasvir) for 24 weeks (Nelson, et al).  Per the guidelines, Sovaldi and ribavirin for 24 weeks is an alternative regimen only for treatment-naive genotype 3 patients who are daclatasvir-ineligible and interferon-ineligible.  The patient is not ineligible for daclatasvir.  In sum, treatment with Sovaldi and Daklinza for 24 weeks is the recommended treatment regimen for patients such as this patient.  There is a lack of support for the requested 12-week course duration of Sovaldi and Daklinza; therefore, the requested medications are not medically necessary for the treatment of this patients hepatitis C virus.  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 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 Sovaldi and ribavirin for treatment of her 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. This applies regardless of fibrosis stage or viral load. Per 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 AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, treatment with Sovaldi and ribavirin  is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer 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: 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 a subcutaneous implantable cardioverter defibrillator for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence supports the requested device in this clinical setting.  In this patients case, placement of a subcutaneous implantable cardioverter defibrillator is considered standard accepted practice.  The placement of a subcutaneous defibrillator has potential long-term advantages in this particular setting.  For this patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Therefore, given the long-term advantages of a subcutaneous defibrillator in this patient and the unlikely need for therapies provided only by an endocardial lead system, the requested subcutaneous implantable cardioverter defibrillator is likely to be superior over other treatment options.  Final Result: Three 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 internal medicine with sub-specialty certification in cardiovascular disease 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 12 units of Sumavel Dosepro per 30 days for treatment of her medical condition.   Findings:  The physician reviewer found that there is sufficient support for the requested medication quantity in this clinical setting.  Sumavel Dosepro is an effective migraine abortive medication.  However, headaches may return, and a second dose in 24 hours may be appropriate. Per the prescribing information, the maximum cumulative dose that may be given in 24 hours is 12 mg, two 6 mg injections separated by at least one hour.  Per the medical evidence, guidance to avoid medication overuse headache is that the patient should not treat more than two to three days per week on average with acute abortive medications.  Thus, the requested medication quantity is medically appropriate.  All told, 12 units of Sumavel Dosepro per 30 days is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication quantity 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 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 Prolia injections for treatment of her osteoporosis.  Findings:  The physician reviewer found that the submitted documentation demonstrates Prolia is medically necessary for this patient. The patient has severe osteoporosis. Recent studies show that patients such as this patient are at a high risk for fracture, as calculated by the FRAX score. Based on the patients submitted medical records, she should continue osteoporosis treatment.  Prolia is approved by the Food and Drug Administration (FDA) for the treatment of osteoporosis in postmenopausal women at high risk of fracture. Prolia reduces the incidence of vertebral fractures by about 68%, hip fractures by about 40%, and non-vertebral fractures by about 20% over 3 years. Based on the submitted records along with the results of available scientific studies, the request for Prolia injections is medically necessary to treat this patients medical condition.Final Result: The 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: Physician reviewer number three is board certified in internal medicine with sub-specialty certification in endocrinology and metabolism 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.