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

Nature of Statutory Criteria/Case Summary: An enrollee is requesting Harvoni for the treatment of his hepatitis C infection. Findings:  The physician reviewer found that according to the 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. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is 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 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 is requesting Harvoni for the treatment of her hepatitis C infection. Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load. The guidelines recommend that treatment-naive genotype 4 patients should be treated with Harvoni for 12 weeks. The guidelines also recommend Technivie/ribavirin for 12 weeks. However, the guidelines specifically recommend against the use of Technivie (or Viekira Pak) with a medication this patient takes.  For these reasons, 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 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 three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Due to the advantages tomosynthesis brings to radiologists in the interpretation of mammograms the American College of Radiology has urged the technique be removed from the investigational category. Tomosynthesis allows the provider to separate dense glandular elements from underlying architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. While there is a lack of long term studies showing an increase in survival rates when tomosynthesis has been added to two-dimensional (2D) imaging, the addition of tomosynthesis was likely of more benefit to the patient than had the mammogram been done with 2D imaging alone. 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 treatment of his medical condition.  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, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin 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.  For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested occupational therapy (sensory integration therapy) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the research around sensory integration therapy or sensory processing disorder is mixed.  There are methodologic flaws in some studies.  However, these methods have been used in schools with good effect for a long time. Parents have particularly reported the benefits of occupational therapy for sensory processing leading to improvements in behavioral regulation and social interactions.  The review done by May-Benson and Koomar showed many benefits to sensory integration approach for children with delays.  There is evidence that occupational therapy with sensory processing intervention is helpful to improve family functioning, improve self-regulation and decrease maladaptive behaviors.  These interventions are better than any other available intervention, including medications or standard occupational therapy.  All told, the requested occupational therapy (sensory integration therapy) is medically indicated for the treatment of 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 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: 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 there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis is of particular benefit in cases of extremely dense and heterogeneously dense breast tissue.  These advantages largely relate to the ability to sort out dense glandular elements from the architectural distortion that is commonly seen in invasive ductal cancer.  The addition of breast tomosynthesis has been associated with a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of tomosynthesis to the two-dimensional mammographic protocol was likely of more benefit for the patient than had her mammogram been done with two-dimensional imaging alone.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested anesthesia services provided during a colonoscopy for treatment of her medical condition. Findings:  The physician reviewer found that monitored anesthesia care was not medically necessary for the patients colonoscopy. The patient did not present with a significant history that would require monitored anesthesia care. The standard of care provides for the use of monitored anesthesia care for minimally invasive procedures if the patient presents with one of the following conditions: airway difficulty, large fluid shifts or co-morbid conditions that put the patient at risk during the procedure. Upon review of the patients medical records, the patient did not meet the criteria for monitored anesthesia care. Procedures like colonoscopy are relatively non-invasive and of short duration; therefore, for some patients, these procedures are well suited to office-based practice. Per American Society of Anesthesiologists (ASA) guidelines, colonoscopy procedures may be safely and effectively performed with conscious sedation of benzodiazepine alone or with a narcotic in an office-based setting without the need of monitored anesthesia care with propofol. A systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in colonoscopy concluded that when moderate sedation is utilized, there is a high level of physician and patient satisfaction while providing low risk of serious adverse events with all currently available agents. In sum, anesthesia services during the patients colonoscopy was not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 treatment of his hepatitis C virus. Findings: The physician reviewer found that according to the 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. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. In addition, guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni has been established as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: 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 inpatient hospital services for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  Based on the medical records, adequate services could not have been delivered in a less restrictive setting at the time.  The patient had a very serious complex addictive disorder.   The services at issue were for active treatment delivered in accordance with a treatment plan and reasonably expected to improve the patients condition.  Finally, the hospital admission facilitated a seamless transfer to a residential chemical dependency program which mitigated the highly probable risk of relapse facing this patient in an unsupervised setting.  In sum, the inpatient hospital services were medically necessary for the patients medical condition.   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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc injections for treatment of his medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested services. There is a lack of adequate randomized, controlled studies in the peer-reviewed literature demonstrating the clinical effect from hyaluronate injections. The use of hyaluronan is not consistently and unambiguously supported by evidence based literature. The basic scientific rationale for hyaluronan effecting arthritis of the knee has not been confirmed. A meta-analysis of the efficacy of viscosupplementation performed by researchers included a total of 89 trials involving 12,667 adults with knee osteoarthritis. The authors concluded that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. In addition, the American Academy of Orthopaedic Surgeons practices guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. In sum, the request for Synvisc injections to be utilized in the management of the patients osteoarthritis is not medically necessary given the lack of support in the evidence based literature.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested substance abuse residential treatment services for treatment of her behavioral health condition. Findings:  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. The patient was not at risk for imminent withdrawals. She was not a threat to herself or others. She was not manic or psychotic. She was medically and psychiatrically stable. She was motivated and engaged. Her level of cravings and medication management did not require a 24-hour setting. The risk of relapse in and of itself is not a reason to keep a patient at a higher level of care in the absence of unstable psychiatric illness or the potential for harm to self or others. The patient received education to provide a better sober environment. Thus, the services at issue were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical spinal fusion (arthrodesis) surgery for treatment of her recurrent neck pain with radiation to bilateral shoulders. Findings:  The physician reviewer found that the submitted medical records do not support the medical necessity of cervical fusion surgery for this patient. The patient does not meet established criteria for cervical fusion surgery. Upon review of the submitted records, there is no evidence the patient has documented instability, fracture or tumor. This patients magnetic resonance imaging (MRI) results do not show severe nerve root impingement or cord compression, as required by guidelines. Furthermore, the patients records do not provide confirmatory evidence that the patient is myelopathic. All told, the patient does not meet accepted clinical indications for cervical spinal fusion (arthrodesis) in this case. As such, the requested procedure is not medically necessary for treatment of the patients recurrent neck pain.Final Result: The reviewer determined that the requested procedure is not medically necessary 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested laboratory testing for the level of infliximab and antibodies in the blood for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Many providers are using this testing as a standard of therapy after starting infliximab to judge whether a patient will benefit from the drug.  The testing allows providers to determine if the serum levels of drug are in the range to be beneficial and effective or if there are antibodies that could potentially lead to a reaction or failure to respond.  This can help guide the provider in dosing or may lead them to discontinue the drug if the patient is not likely to benefit from the medication.  This can not only prevent the patient from having a flare up but save them from potential side effects of a drug they may not benefit from.  All told, the services at issue were likely to have been of greater benefit than other methods of evaluating this patient.  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 pediatrics with sub-specialty certification in pediatric gastroenterology 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.