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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg for treatment of the enrollees 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 (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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These 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 infection, regardless of fibrosis stage. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Mavyret 100-40 mg is medically necessary 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: The patient has requested authorization and coverage for Mavyret 100 mg/40 mg, three tablets daily, for eight weeks for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 1a. 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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret for eight weeks. These 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 ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret 100 mg/40 mg, three tablets daily, for eight weeks 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 reimbursement for immunoglobulin G (IgG) testing (CPT 86001 x 6) for evaluation of the enrollee, who reported a history of chest tightness and pressure. Findings:  The physician reviewer found that allergic bronchopulmonary aspergillosis (ABPA) is an immunologic bronchopulmonary inflammation due to an immune response against Aspergillus fumigatus. The major clinical features of ABPA include asthma, recurrent pulmonary infiltrates, immediate wheal-and-flare skin reactivity to Aspergillus fumigatus, elevated total serum immunoglobulin E (IgE) levels, detectable serum precipitating antibodies to Aspergillus fumigatus, peripheral blood eosinophilia, elevated levels of Aspergillus-specific serum IgE and central bronchiectasis. The diagnosis of ABPA should be suspected in asthmatics or patients with allergic disease, with evidence of central bronchiectasis or recurrent atelectasis in chest imaging. The medical evidence support further evaluation in this setting. In this patients case, the clinical data are sufficient to support a high clinical suspicion for ABPA to warrant the tests in review. Therefore, the services at issue were likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Two of 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: Physician reviewer number one is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in allergy and immunology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Standard Review The patient has requested authorization and coverage for Epclusa for 12 weeks. The Health Plan has denied this request indicating that the requested medication is not medically necessary for treatment of the enrollees chronic hepatitis C virus (HCV) genotype 2b. Nature of Statutory Criteria/Case Summary: 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. This applies regardless of fibrosis stage, and advanced fibrosis is not required for treatment. Per the guidelines, Epclusa is recommended as first-line therapy for treatment naive genotype 2 patients, based on clinical trials including ASTRAL-1 and ASTRAL-2, which showed a 99% cure rate and superiority to Sovaldi with ribavirin (Feld, et al; Foster, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested Epclusa for 12 weeks 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 evaluation 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 authorization and coverage for Humalog and Lantus in the pen form for treatment of the enrollees type 2 diabetes. Findings:  The physician reviewer found that The there is sufficient support for the requested medications in this clinical setting. The most recent American Diabetes Association standards of diabetes care state that a patient-centered approach should be used to guide the choice of pharmacologic agents. Considerations include efficacy, hypoglycemia risk, history of atherosclerotic cardiovascular disease, impact on weight, potential side effects, renal effects, delivery method (oral versus subcutaneous), cost, and patient preferences. In a study which included 13,428 patients by Ayyagari and colleagues, the authors noted adherence and pen use have beneficial effects on patients real-world outcomes, with the most favorable effects attributable to adherent pen use. This patients diabetes is poorly controlled. Allowing the patient to self-administer his required insulin via insulin pens is medically necessary to optimize his diabetes control and outcomes, and prevent diabetes-related morbidity and hypoglycemia. All told, Humalog and Lantus in the pen form are medically necessary 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 endocrinology, diabetes 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 authorization and coverage for Mavyret for treatment of the enrollees chronic hepatitis C virus (HCV), genotype 1a. 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 all patients should be treated, regardless of fibrosis stage. As ultrasound elastography showed a lack of cirrhosis, thus this patient should be treated as a non-cirrhotic patient.  The guidelines recommend that non-cirrhotic treatment naive genotype 1a patients should be treated with Mavyret. These 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 ENDURANCE-1 trial showed that only eight weeks of treatment is needed. The patient has an isolated positive core antibody, with negative surface antigen and antibody, most consistent with resolved infection, or less likely a false-positive anti-core antibody. In this case, the patient had no detectable hepatitis B viral load, and does not have an active infection. Even if the patient had active hepatitis B, the AASLD/IDSA guidelines state that [Hepatitis B surface antigen] HBsAg positivity does not represent a contraindication to HCV [direct acting antivirals] DAA therapy. Guidelines further that There are insufficient data to provide clear recommendations for the monitoring of hepatitis B DNA among patients testing positive either for anti-HBc alone (isolated anti-HBc) or for anti-HBs and anti-HBc (immune recovery). Therefore, there is no hepatitis B-related contraindication to starting Mavyret therapy in this case. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Mavyret is supported as medically necessary for the treatment of the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Euflexxa knee injections for treatment of the enrollees osteoarthritis of the left knee. Findings:  The physician reviewer found that Evidence based medical peer-reviewed literature supports the use of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  The American Medical Society for Sports Medicine recommends hyaluronan acid for appropriate knee osteoarthritis patients, based on a large network meta-analysis. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement, and more effective than corticosteroid injections. In this case, the patient presents with severe left knee pain with associated crepitance and limited motion. She reports functional difficulty in walking. Clinical examination findings are consistent with reported radiographic evidence of the left knee osteoarthritis. She has failed to improve with at least three months of conservative treatment, including activity modification, nonsteroidal anti-inflammatory drugs, and a corticosteroid injection. Therefore, the request for Euflexxa injections for the left knee are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services 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 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: The parent of the enrollee has requested authorization and coverage for 120 hours per month of direct applied behavior analysis (ABA) services and 24 hours per month of supervision for treatment of the autism spectrum disorder. Findings:  The physician reviewer found the request for 120 hours per month of direct ABA services and 24 hours per month of supervision are medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, the patient has made slow progress in many areas of his skill acquisition goals. The patient continues to require a high level of support to transition appropriately. Failure to master these skills puts the patient at an increased risk for injury, and makes it increasingly difficult to be successful in more generalized environments. In addition, several studies recommend 25 or more hours of weekly ABA to ensure optimal outcomes. Given the medical necessity of ABA services for children with autism and the clinical documentation supporting a higher level of support for this patient, the requested services are medically necessary for treatment of the patients medical condition. 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Concerta for treatment of the enrollees attention deficit hyperactivity disorder (ADHD). Findings:  The physician reviewer found that stimulant medication is the gold standard pharmacologic intervention for ADHD. Concerta is a methylphenidate-based product approved by the U.S. Food and Drug Administration (FDA) for the treatment of ADHD. Concerta is a central nervous system psychostimulant that has been shown to exert its clinical effect by blocking the reuptake of norepinephrine and dopamine in the prefrontal cortex. The unique extended-release tablet relies on osmotic pressure to steadily deliver methylphenidate resulting in a duration of effect that can approach 12 hours. The typical dose range of Concerta is between 18 mg and 72 mg once a day. In this case, the patient was previously treated with Concerta, and this represents the most critical factor in the determination process of this particular case. This patient has a proven track record of tolerability and efficacy with Concerta. Additionally, upon continuing care for his ADHD, Concerta was prescribed by his treating provider at a safe, appropriate and conservative dose. Given that the patient has performed well with Concerta, the requested medication has been established as medically necessary for treatment of the patients ADHD. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Mavyret 100-40 mg, three tablets daily, for eight weeks. 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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1a patients should be treated with Mavyret for eight weeks. These 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, Mavyret 100-40 mg, three tablets daily, for eight weeks is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication regimen 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 authorization and coverage for hydromorphone ER 8 mg (Exalgo ER). Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication. While high-dose opiates carry substantial risks, the plan to continue opiates must be reviewed with the patient. While a taper may be offered to the patient, it is not required that every patient be tapered. In this patients case, opiate rotation may be beneficial and is an appropriate option. The current medical evidence supports the requested medication in this clinical setting. All told, hydromorphone ER 8 mg (Exalgo ER) is medically necessary 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for Carimune intravenous immunoglobulin (IVIG). Findings:  The physician reviewer found that this patient has demonstrated hypogammaglobulinemia by both serum immunoglobulin levels and the lack of antibodies directed against polysaccharide pneumococcal vaccine, a rigorous test of humoral immunity. Clinically, this manifests with recurrent viral syndromes including serositis with very high systemic inflammation markers such as C-reactive protein (CRP). This patient has been closely clinically followed by his provider. Treatment with IVIG to prevent such recurrent infections is consistent with standard medical practice and evidence for use in this clinical setting. Thus, the requested Carimune IVIG is medically necessary for treatment of this patients hypogammaglobulinemia. 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 medical 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.