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 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, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials.  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 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 Sovaldi and ribavirin for 12 weeks for treatment of her hepatitis C virus.   Findings:  The physician reviewer found that according to the most recent guidelines issued, 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-experienced genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for a minimum of 16 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. The guidelines reflect a medical trial, which showed higher efficacy with 16 rather than 12 weeks of treatment. The guidelines also cite data showing increased survival with earlier treatment. In this clinical setting, Sovaldi and ribavirin for 16 weeks is clinically indicated for the treatment of this patients hepatitis C infection. However, Sovaldi and ribavirin for 12 weeks is not supported as medically necessary.  Final Result: The reviewer determined that the requested medications 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 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 Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that per the most recent guidelines issued, all patients with chronic hepatitis C should be treated regardless of fibrosis except those with limited life expectancy due to non-liver-related conditions. However, the requested regimen of Sovaldi and ribavirin for 24 weeks is no longer recommended by the guidelines. Non-cirrhotic genotype 3 patients who have failed PEG-interferon and ribavirin are recommended to be treated with Sovaldi, PEG-interferon, and ribavirin for 12 weeks or Sovaldi and Daklinza for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Sovaldi and ribavirin for 24 weeks is not supported as medically necessary for the treatment of this patients hepatitis C virus. Final Result: The reviewer determined that the requested medications 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 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 weekly individual psychotherapy for treatment of her behavioral health condition.  Findings:  The physician reviewer found that effective psychotherapy is a trusted intervention in the treatment armamentarium for those afflicted with major depressive disorder, PTSD and hoarding.  Current practice in this country is focused on aggressive treatment in the acute phase of these illnesses, in which more restrictive settings such as IOP may be necessary, followed by progressively less intensive services in the maintenance phase to foster patient autonomy and recovery.  In this particular case, it does not appear that the patient has received an evidence-based exposure therapy or behavioral therapy during the episode of illness. Further, recalling that depressive disorders are often chronically recurring conditions, the patient was described as having significant affective symptoms. Although supportive group therapies are an important complementary intervention in any case, the patients current plan is both inadequate for therapeutic consolidation and inconsistent with good medical practice. In accordance with the American Psychiatric Association (APA) clinical practice guideline, a course of individual sessions should be pursued. APA guidelines further state If 4-8 weeks of treatment do not yield at least moderate improvement (20% diminution in symptoms), the clinician should thoroughly review and reappraise the treatment plan. For the reasons provided above, weekly individual psychotherapy sessions 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 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 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, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with 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.  All told, 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested an insulin pump for the treatment of the enrollees medical condition.  Findings: The physican reviewer found that this patient has a history of widely fluctuating blood glucose levels before meals, glycemic control that is suboptimal, and variations in her daily activity schedule and eating plan such that a multiple dose injection regimen is unlikely to be adequate to maintain glycemic control and prevent severe hypoglycemia. Several studies published in peer-reviewed journals have shown that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes.  Compared with conventional insulin treatment, continuous subcutaneous insulin infusion improves glycemic control, limits excessive weight gain and reduces the frequency of hypoglycemic events.  All told, the requested insulin pump is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in pediatric 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi 400 mg for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that pursuant 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. The patients prior treatment status is not clearly documented in the records provided. Regardless of his treatment history, Sovaldi should not be used as monotherapy. The guidelines recommend either Sovaldi or Daklinza for 12 weeks or Sovaldi, peg-interferon and ribavirin for 12 weeks. This recommendation is based on the ALLY-3 and EUCUP trials.  The BOSON trial demonstrated efficacy for Sovaldi with peg-interferon and ribavirin (Foster et al). For these reasons, medical necessity for monotherapy with Sovaldi 400 mg has not been established.  Final Result: The reviewer determined that 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested allergy testing for evaluation of her medical condition.  Findings: Three physician reviewers found that, although higher concentrations of food-specific antibodies correlate to an increased likelihood of a reaction upon ingestion, an individual patient with a significant food allergy can have a high, medium, low, or even negative in vitro test.  Additionally, a patient can have a low positive test for a food to which they are tolerant.  Thus, the patients clinical history is critical to both determining the tests to perform and confirming the diagnosis.  Large panels of testing rarely provide useful information and are not performed as the standard of care for the work-up of this patients symptoms.  Therefore, the services at issue were not likely to have been of greater benefit than other modalities.  Final Result: Three physician reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:   All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic testing for evaluation of her medical condition. Findings: Two physician reviewers found that there are now multiple gene assays to further refine our understanding of the biology of an individuals breast cancer.  The current guidelines make reference to the Oncotype DX assay.  However, the MammaPrint, a 70 gene assay, has been fairly well-accepted by the oncology community, as an alternative to the Oncotype DX assay, in determining the need for adjuvant chemotherapy.  This assay does give an estimate of the risk of recurrence, and thereby is useful in considering adjuvant chemotherapy.  Thus, there is sufficient support for the MammaPrint portion of the services at issue.  TargetPrint determines the activity of a particular gene, which might be a superior assay for certain signatures, but as of yet its clinical utility has not been proven.  BluePrint is an assay designed to classify a patients breast cancer into specific molecular subtypes, such as luminal or basal-like types.  There is no known additional clinical benefit from this assay, above and beyond the MammaPrint assay.  In sum, the MammaPrint portion of the services at issue was likely to have been more effective than other modalities.  However, the superior efficacy of the remainder of the services at issue has not been established.  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 partially overturned.  Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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 hepatitis C virus.  Findings: The physician reviewer found that Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest American Association for the Study of Liver Diseases and Infectious Diseases Society of America (AASLD/IDSA) recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per current AASLD/IDSA guidelines, the medical appropriateness of therapy as proposed exists regardless of fibrosis score. According to the AASLD/IDSA guidelines, Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). As such, the proposed regimen of Harvoni is medically necessary for treatment of the 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Rituxan for treatment of his medical condition.  Findings:  The physician reviewer found that the patient has a history consistent with multiple sclerosis, and he has tried a medication.  The records indicate a decline in mobility.  Rituxan is an anti-CD20 monoclonal antibody that has been studied in multiple sclerosis treatment.  Researchers performed an analysis of clinical trials with Rituxan in multiple sclerosis and noted that they were unable to give any clear recommendations for the use of Rituxan as a therapy for relapsing-remitting multiple sclerosis.  According to the researchers, the potential benefits of this medication for patients with relapsing-remitting multiple sclerosis need to be evaluated in large scale studies along with long-term safety. Disability progression and quality of life should be addressed in future research.  In this patients case, the records do not indicate treatment with any of the other U.S. Food and Drug Administration (FDA) approved disease modifying medications for treatment of relapsing-remitting multiple sclerosis, which have established safety and efficacy profiles.  All told, Rituxan is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that 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 neurology 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 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. 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 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines state that patients with diabetes mellitus are at high risk for fast progression of fibrosis. Per the guidelines, treatment-experienced genotype 1 patients should be treated with Harvoni for 12 weeks. This guideline recommendation is 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: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with 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.