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 Zepatier 50/100 mg tablets for 16 weeks 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment-naive, genotype 1a patients should be treated with Zepatier with ribavirin for 16 weeks when NS5A resistance is present. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, treatment is needed regardless of fibrosis stage, and Zepatier 50/100 mg tablets for 16 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 reimbursement for hyaluronan/Orthovisc to bilateral knees provided. Findings:  The physician reviewer found that the evidence-based peer-reviewed literature supports the use of repeat viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement. This treatment has been found to be more effective than corticosteroid injections. In this case, the patient has been diagnosed with bilateral knee osteoarthritis. She reported recurrent bilateral knee pain affecting her ability to perform activities of daily living. She had undergone prior series of viscosupplementation for each knee, with documentation of improvement in pain and functional ability. Conservative treatment was documented to include anti-inflammatory medications, analgesic medication, and corticosteroid injections, with little to no relief. The medical evidence supports the services at issue in this clinical setting. All told, hyaluronan/Orthovisc to bilateral knees provided on were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: An enrollee has requested reimbursement for hyaluronan derivative Euflexxa injections for treatment of the enrollees bilateral knee pain. Findings:  The physician reviewer found that current evidence based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for patients with osteoarthritis who have not responded adequately to conservative treatments for at least three months, including failure to adequately respond to aspiration and injection of intra-articular steroids. The medical literature supports hyaluronic acid injections to potentially delay total knee replacement for patients with pain that interferes with functional activities. The literature also states that if there is documented significant improvement in symptoms for six months or more, and symptoms recur, it may be reasonable to do another series. High quality scientific evidence does not appear to place a maximum amount of injections that an individual may receive for treatment of osteoarthritis of the knee. Moreover, hyaluronate treatment has been shown to be safe and effective. In this case, the patient has been diagnosed with advanced bilateral knee osteoarthritis. Functional limitations have been reported in activities of daily living. Clinical examination findings have been consistent with reported advanced arthritis. The patient underwent previous series of Euflexxa injections to both knees with significant pain reduction which was noted for at least six months. The patient was unable to take NSAIDs due to a kidney condition and conservative treatment including exercise have failed to provide sustained improvement. Final Result: The reviewer determined that the injections at issue were 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 enrollee has requested authorization and coverage for Zepatier 50/100 mg tablets for 12 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. This recommendation applies to all patients, regardless of fibrosis stage. The guidelines recommend that treatment naive genotype 1a patients should be treated with regimens including or Zepatier for 12 weeks when NS5A resistance is not found. These guideline recommendations are based on clinical trial results showing a 99% cure rate when NS5A resistance is absent. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting. Genetic testing of thyroid nodules is generally considered standard protocol on fine needle aspirations. There is sufficient literature indicating that this test can be performed to avoid unnecessary surgeries. In this case, the Afirma Gene Expression Classifier testing results were suspicious, so further surgical management was required. Thus, Afirma Gene Expression Classifier testing was likely to have been more effective than other options for evaluating this patient. Final Result: The 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: Reviewers 1, 2 and 3 are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. The 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 authorization and coverage for TiLite titanium wheelchair (or a wheelchair comparable to the same model she has been using). Findings:  The physician reviewer found that the patient has a history of spina bifida and is a long term wheelchair user. The patient has developed a gluteal pressure ulcer attributed to the fit of the wheelchair and back angle. There is no new injury or change in this patients neurological condition. Accordingly, the pressure ulcer can be attributed to her current seating system. The patient requires a replacement wheelchair as her current chair cannot be adjusted in terms of its back angle. A 90 degree back would be expected to distribute seating pressures evenly over the weight-bearing surface and limit shear forces. A repair of her current wheelchair would not resolve this patients pressure ulcers. For these reasons, the TiLite titanium wheelchair (or a wheelchair comparable to the same model she has been using) is medically necessary for the treatment of this patients medical condition. 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A transgender enrollee has requested authorization and coverage for facial laser hair removal for treatment of the enrollees gender dysphoria. Findings:  The physician reviewer found that the requested services are medically necessary in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Excessive facial hair in a female would be considered abnormal and is referred to hirsutism. Hirsutism is a medical diagnosis where terminal hair grows in female in areas that are normally found in males. This would include the face and parts of the genitalia. A female would be expected to have terminal hair in the scalp, axilla and on the arms and legs. This patients excessive facial hair is more consistent with the male gender. Additionally, hormone therapy has not been effective in improving this patients medical condition. Therefore, facial hair removal is medically necessary for the treatment of this patients gender dysphoria. With regard to whether the requested services are considered reconstructive in nature, excessive facial hair in a female is an abnormal body structure.  Hirsutism is a condition that is congenital in that the hair growth is determined by the genetic and hormonal makeup of the patient. As such, the requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible in this patient. Moreover, the requested services are going to improve emotional function for this patient. Final Result: The reviewer determined that the requested services are medically necessary and are reconstructive in nature 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Uceris 9 mg extended release tablets for treatment of the enrollees microscopic colitis. Findings:  The physician reviewer found that the request for Uceris 9 mg extended release tablets is medically necessary for treatment of the patients medical condition. Microscopic colitis consists of chronic or intermittent watery diarrhea, accompanied by abdominal pain, weight loss, incontinence and arthralgias. No alterations in the large bowel are visibly appreciated by endoscopic and radiologic evaluation, so definitive diagnosis is made by histological analysis. There are two subtypes: collagenous colitis and lymphocytic colitis. No differences are appreciated in clinical presentation and management, but collagenous colitis is distinguished by a thickening of the subepithelial collagen layer that is absent in lymphocytic colitis. There is sufficient medical literature supporting the use of Uceris for the treatment of collagenous colitis. According to researchers, Recent evidence has added new pharmacological options for the treatment of microscopic colitis: the role of steroidal therapy, especially oral budesonide, has gained relevance, as well as immunosuppressive agents such as azathioprine and 6-mercaptopurine. Munch and colleagues performed a prospective, randomised, placebo-controlled study in patients with histologically confirmed active collagenous colitis who received budesonide. The authors concluded that Budesonide at a mean dose of 4.5 mg/day maintained clinical remission for at least 1 year in the majority of patients with collagenous colitis and preserved health-related quality of life without safety concerns. Uceris appropriately targets the delivery of budesonide to the colon, and has shown efficacy and tolerance in 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 reimbursement for the continuous passive motion (CPM) machine for treatment of the enrollees left hip status post arthroscopy.  Findings:  The physician reviewer found that in the medical literature, it is noted that some patients are treated post-operatively with a CPM machine and a hip brace. The authors state that athletes undergoing the procedure may have an accelerated timetable, based on the underlying pathology. Recognizing the patients pre-operative health status and post-operative physical demands will direct both the program design and the program timetable. The CPM is used for three weeks and the brace for 10 days. The CPM is adjusted to allow protected motion within the parameters set by the provider. In this case, the CPM machine was prescribed for post-operative use in a young athlete. Consistent with the current scientific data, the use of the CPM machine was appropriate, reasonable, and medically necessary following this patients hip arthroscopy. Final Result: The reviewer determined that the device at issue was 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: An enrollee has requested authorization and coverage for Xenical 120 mg for treatment of obesity and chronic back pain. Findings:  The physician reviewer found that current medical literature supports the requested medication in this clinical setting and supports an exception to the formulary alternatives. This patient has been diagnosed with class II obesity and has not sustained durable success with diet, exercise or with weight loss medications phentermine or topiramate. The patient also has comorbidities such as obstructive sleep apnea and low back pain. Guidelines for pharmacological management of obesity released in 2015 by the Endocrine Society state that patients who have a history of being unable to successfully lose and maintain weight loss are candidates for weight loss medications. Specifically, pharmacotherapy is recommended in patients with BMI higher than 30 kg/m2 or 27 kg/m2 if comorbidities are present. Xenical is U.S. Food and Drug Administration approved at the dose of 120 mg, three times daily for chronic weight management in patients with BMI over 30 kg/m2, or 27 kg/m2 with comorbidities (Package insert). This patient has a BMI of 37 kg/m2. 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 expertise in weight 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for balloon sinus ostial dilation for treatment of the enrollees sinusitis.  Findings:  Three physician reviewers found that at present, functional endoscopic sinus surgical techniques for the management of chronic rhinosinusitis refractory to medical management are still considered the surgical treatment of choice. Balloon sinus ostial dilation is a technique to improve patients symptoms of recurrent acute rhinosinusitis to help widen and dilate the sinus pathways.  Some data report improvement in patient symptoms with this technique. However, this patient does not meet clinical medical criteria for surgical treatment of the paranasal sinuses based on the findings documented in the medical reports. Final Result: The reviewers determined that the requested procedure is 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: Reviewers 1, 2 and 3 are board certified in otolaryngology and are actively practicing. The 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 authorization and coverage of Xifaxan (rifaximin) 550 mg three times daily for 14 daysFindings:  The physician reviewer found that there is support in the medical literature for the medical necessity of the requested medication in this clinical setting. Xifaxan has been proven effective for the treatment of irritable bowel syndrome, diarrhea-predominant. Unlike alternatives, the U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D. The medication has been proven safe and effective in randomized placebo controlled trials for IBS-D. In the TARGET-3 trial of over 1,000 patients, Xifaxan 550 mg three times daily (the requested dose) proved effective with significant symptom improvement in irritable bowel syndrome. The American College of Gastroenterology guidelines for the treatment of irritable bowel syndrome state that Xifaxan is effective. The patient has already attempted alternatives such as dicyclomine with adverse effects. Additionally, the patient has small intestinal bacterial overgrowth and failed Augmentin. Xifaxan has proven highly effective in small intestinal bacterial overgrowth for eradication of bacteria and symptom relief . For bacterial overgrowth, eradication was demonstrated in 80% versus 54% for placebo. The medication had greater effectiveness with fewer side effects than antibiotic alternatives such as metronidazole, neomycin, and fluoroquinolones such as ciprofloxacin .  Results are sustained for several weeks after treatment. For these reasons, Xifaxan 550 mg three times daily for 14 days is supported as medically necessary for the treatment of this patients medical condition.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.