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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Ibrance for treatment of her breast cancer.  Findings:  The physician reviewer found that patients with advanced cancers whose tumors have progressed on standard regimens will inevitably be treated with agents off of U.S. Food and Drug Administration (FDA) labels. In this case, it is important to evaluate the medical evidence to see if such agents have efficacy and are safe. Palbociclib inhibits cyclin-dependent kinases 4 and 6, which may account for resistance to endocrine therapy. Ibrance is FDA approved for first-line therapy of ER-positive, HER2-negative metastatic breast cancer in postmenopausal women in combination with letrozole. In a trial, 165 patients were randomized to letrozole or letrozole/palbociclib and the latter regimen conferred increased progression-free survival (PFS) of 20.2 months versus 10.2 months, a finding of high statistical significance. In this clinical trial, enrolled patients had no prior endocrine therapy and were postmenopausal. In contrast, another trial enrolled patients who had prior endocrine therapy and allowed both premenopausal and postmenopausal patients. Patients were randomized to fulvestrant or fulvestrant/palbociclib. The latter combination treatment showed significantly increased PFS. This patient matches those evaluated in the clinical trials.  The patient has had a response to the current regimen and it is in her best interest to continue the present therapy. There is sufficient medical evidence to support palbociclib as medically necessary, safe, and appropriate in this clinical setting. 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 oncology and hematology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that in managing patients with chronic hepatitis C virus, 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. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. Moreover, 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. For the reasons provided above, the request for Harvoni for 12 weeks is medically necessary for treatment of the patients hepatitis C virus genotype 1.   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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an orthotic shoe insert for treatment of the enrollees medical condition.  The physician review found that this patient has documented diagnoses of plantar fasciitis left side, pain in limb left side, and posterior tibial tendonitis left side.  Root type orthotics, which have been prescribed by this patients provider, have been used for many years for the treatment of lower extremity and foot pain.  The orthotics have been recommended to reduce abnormal biomechanics of this patients foot, alleviating pressure to the origin of the plantar fascia as well as the insertion of the posterior tibial tendon left side.  In this case, the orthotics are being used to correct abnormal biomechanics.  All told, the requested orthotic shoe insert 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 podiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent basis.  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with an upper respiratory infection. The patient was a non-smoker and there was no evidence of shortness of breath, weakness, hemoptysis, nausea/vomiting, or significant pain or disability. Moreover, the patient was not in acute distress and there was nothing in the patients history, physical exam, or ER evaluation that indicated any emergent or even urgent medical condition. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not experiencing a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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 medical condition.  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening films has gained wide support among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  In this patients case, the addition of digital breast tomosynthesis was likely to have been more beneficial than digital mammography without tomosynthesis.  All told, the medical records establish the superior efficacy of breast tomosynthesis.  Final Result: Three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested applied behavioral analysis (ABA) services, supervision and parent training for treatment of his autism spectrum disorder. Findings:  Three physician reviewers found that the medical evidence supports the requested services in this clinical setting.  At issue is the notion that plasticity in the developing brain, albeit a brain with underlying neurologic disease, exists and can be utilized to improve overall neurologic health.  Thus, a treatment paradigm like ABA has the potential to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism spectrum disorder.  Thus, the requested ABA therapy, supervision and parent training are medically indicated for the treatment of this patient. Final Result: Three reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in neurology with special qualification in child 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested durable medical equipment (DME) items external ambulatory infusion pump, external transmitter, continuous glucose monitor (CGM) disposable sensor, and CGM SY external receiver for treatment of his diabetes with hypoglycemic unawareness. Findings:  The physician reviewer found that this patients records do not include a clinical indication for the requested equipment in order to properly manage his diabetes. There is no reason given why the patient needs a new CGM and pump. Further, the requested system has not been demonstrated to be superior for management of this patients condition when compared to the current CGM and pump already in use. Accordingly, the requested DME items external ambulatory infusion pump, external transmitter, continuous glucose monitor (CGM) disposable sensor, and CGM SY external receiver are not medically necessary for treatment of this 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Botox injection on the forehead for treatment of his hyperhidrosis. Findings: The physician reviewer found that hyperhidrosis is excessive sweating beyond that required to return body temperature to normal. It can be localized or generalized, commonly affecting the axillae, palms, soles or face, and can have a substantial negative effect on a patients quality of life. Botox acts by inhibiting the release of acetylcholine at the presynaptic membrane of cholinergic neurons. Botox has revolutionized the treatment of focal hyperhidrosis in recent years and has dramatically reduced the need for invasive surgical techniques to control severe focal hyperhidrosis unresponsive to topical therapies. There is growing evidence that Botox is an efficient and appropriate treatment for forehead hyperhidrosis. Previous treatment of this patient with Botox has been very effective. Therefore, it should be considered as the most appropriate and should not be substituted with other methods or surgery. Consistent with this support, the requested Botox injections on the forehead is medically necessary for treatment of this patients hyperhidrosis. 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 dermatology 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:    The parent of an enrollee has requested gene testing (exome sequence analysis) for evaluation of the enrollees autism spectrum disorder and intellectual disability. Three physician reviewers found that the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The lack of a diagnosis can have considerable adverse effects for patients and their families, including failure to identify potential treatments, failure to recognize the risk of recurrence in subsequent pregnancies, and failure to provide anticipatory guidance and prognosis. A long-term search for a genetic diagnosis, referred to as the diagnostic odyssey, also has implications for societal medical expenditures, with unsuccessful attempts consuming limited resources. This patient is an appropriate candidate for the requested exome sequence analysis as it is 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 testing is 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: One reviewer is board certified in pediatrics with sub-specialty certification in clinical genetics and is actively practicing. One reviewer is board certified in pediatrics and genetics and is actively practicing.  One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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: 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 her hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting. The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  In this patients case, Harvoni for 12 weeks is medically indicated to prevent further progression of fibrosis.  All told, Harvoni for 12 weeks 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his hepatitis C.   Findings:  The physician reviewer found that the current medical evidence supports the requested medications in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The guidelines note that the medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  For this patient, withholding treatment will cause further progression of fibrosis.  All told, Sovaldi and ribavirin for 12 weeks is medically indicated for the treatment of this patient. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni for 12 weeks as a Class I, Level A recommendation. These guideline recommendations are based on multiple randomized clinical trials, and the medication is FDA-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Based on evidence of safety and efficacy in the published literature and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. 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 the LifeVest for treatment of his dilated cardiomyopathy.  Two physician reviewers found that based on the records provided, the patient is a 19-year-old male with a newly recognized dilated cardiomyopathy. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy. In addition, there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time, about 40 days after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist despite of appropriate treatment. Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome. A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. Accordingly, the LifeVest was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the device at issue was 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 cardiology 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.