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 eight weeks for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendation of Class I, Level A recommendation for treatment of HCV patients. Although the documentation submitted for review do 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 stating Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months).  Therefore, Harvoni for eight weeks is medically necessary for treatment of the patients HCV. 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 a 12-week course of Harvoni 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 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. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 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 parent of an enrollee has requested circumcision for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the American Academy of Pediatrics (AAP) recently published a policy statement regarding circumcision in support of the procedure. The AAP has indicated that the benefits outweigh the risk, recommending circumcision for any neonatal infant in whom there are no medical contraindications, and accepting family preference. The Center for Disease Control (CDC) has taken this stance even further, recommending discussion with adolescent and adult men regarding benefits and risks of circumcision surgery. Benefits include prevention of urinary tract infection, acquisition of human immunodeficiency virus (HIV), transmission of some sexually transmitted infections, and penile cancer. Based on these current recommendations, circumcision after the neonatal period is medically necessary and medically appropriate for this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics and pediatric critical care 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 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 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. AASLD guidelines cite data showing reduced survival with delayed treatment.  For these reasons, the requested treatment with Harvoni 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 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 evaluation of her medical condition. Findings:  Two physician reviewers found that the addition of breast tomosynthesis to routine screening has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  The added benefit occurs due to the ability of radiologists to separate glandular overlying tissue from underlying architectural distortion or mass which in turn improves reader confidence.  Thus, the addition of breast tomosynthesis to the usual screening films was likely to have been of greater benefit to the patient than digital screening mammography without tomosynthesis.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: 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 virus (HCV). Findings:  The physician reviewer found that 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 dermatology services for treatment of her scalp lesion. Findings:  The physician reviewer found that the patient presents with a history of basal cell carcinoma and is requesting dermatology services related to a scalp lesion. The patient complains of blisters on the skin which could be an indication of an autoimmune blistering disorder, such as pemphigus vulgaris of bullous pemphigoid. Additionally, the patient has a history of basal cell carcinoma, which in and of itself, is an indication for routine dermatology evaluation as yearly skin exams are recommended for those with a history of skin cancer. Given the potential for a serious skin disease such as pemphigus vulgaris, bullous pemphigoid, or bullous impetigo and history of skin cancer, the request for dermatology services is medically necessary.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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested a neuropsychology consultation for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. The diagnosis of autism is usually made with specific instruments such as the Childhood Autism Rating Scale (CARS) or other standardized scales. The diagnostic testing for autism is typically performed by a psychologist, not a neuropsychologist.  After the diagnosis has been made, patients often are referred for applied behavior analysis (ABA) therapy to design a treatment program. In this case there is a lack of rationale provided for the requested neuropsychology consultation. For the reasons stated, the requested services are not medically necessary in this clinical setting.Final Result: The reviewer determined that the requested services 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 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. In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the brand name medication Synthroid for the treatment of her hypothyroidism.   The physician reviewer found that Levothyroxine is the standard of care for treating hypothyroidism.  However, in this patients case, levothyroxine has caused an adverse event.  Therefore, the requested brand name medication Synthroid is medically necessary in this clinical setting.  Levothyroxine is designated as a drug with a narrow therapeutic index (NTI).  Slight increases or decreases in serum thyroid stimulating hormone (TSH) levels can potentially result in adverse effects due to toxicity or lack of efficacy.  Because there are numerous manufacturers of generic levothyroxine and the preparation varies among the generic equivalents, it is more difficult to maintain steady therapeutic levels on the generic levothyroxine than on the branded medication.  All told, the requested brand name medication Synthroid 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 endocrinology 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.  Findings:  Three physician reviewers found that  breast tomosynthesis has been widely embraced by radiologists due to an associated decrease in callbacks and increase in detection of small cancers due to the tomographic qualities of the additional technique.  This allows the radiologist in many instances to sort out dense glandular tissue from underlying architectural distortion and mass, thereby improving the accuracy and confidence of the interpretation.  This is especially true in cases of very dense and heterogeneously dense breast tissue.  Thus, the addition of breast tomosynthesis was more likely of benefit to the patient than if the study had been done without the three-dimensional technique. 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 Sovaldi and ribavirin for 12 weeks for treatment of her 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.  Per the guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based 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.  All told, Sovaldi and ribavirin for 12 weeks are 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 an eight-week course of 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.  Per the guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients.  Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight 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 eight-week course of 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that direct acting antiviral therapy should be prioritized for those who would be most likely to benefit in the near-term, as recommended by the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA). The highest priority patients include those who are at highest risk of substantial morbidity and mortality from untreated hepatitis C infection, namely those with advanced fibrosis (F3) or compensated cirrhosis, and those with severe extrahepatic manifestations of hepatitis C infection. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis (F2), HIV coinfection, coexisting liver disease, and diabetes mellitus. Therefore this patient would not be considered a high priority patient. Although recommendations from the AASLD state that even non-priority patients should be treated if their life expectancy is estimated to be greater than 12 months, the exceptions to this include patients who have demonstrated evidence of non-compliance or are actively using alcohol or illicit substances. This patient has tested positive for an illicit substance. Given the combination of minimal fibrosis (F1) along with substance use the requested medication is not medically necessary in this clinical setting.  Final Result: the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12-week course of Viekira Pak 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, treatment-naive genotype 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials. 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 guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Viekira Pak 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 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.