Persius/hicric huggingface dataset:
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 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), treatment is recommended for all patients with chronic hepatitis C infection, except those with short life expectancies that cannot be remediated by treating hepatitis C by transplantation, or by other directed therapy. However, in this case the patient presents without fibrosis and has a viral load of less than six million IU/mL. In this clinical setting, given the patients viral load of less than six million IU/mL Harvoni for eight weeks is clinically indicated. As such, Harvoni for 12 weeks is not medically necessary for treatment of the patients medical condition.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of his psoriasis. Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. The patient presents with psoriasis and a history of elevated liver enzymes, making certain medications unfavorable therapy candidates for this patient. However, the patient has not had failure or intolerance of certain biologics. He has not failed therapy with phototherapy.  There is no mention in the medical records of a contraindication to treatment with phototherapy, or certain biologics. Given that the patient has not failed other systemic therapies, the request for coverage of Otezla is not medically necessary for treatment of the patients medical condition.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 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 Harvoni for eight 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, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below six million 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. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested deep brain stimulation for treatment of his Parkinsons disease. Findings:  The physician reviewer found that deep brain stimulation (DBS) is a U.S. Food and Drug Administration (FDA) approved treatment for advanced Parkinsons disease. The medical  literature review states From the evidence available, we conclude that surgical management of [Parkinson disease] PD alone or in combination with medical therapy results in greater improvement of motor symptoms and quality of life than medical treatment alone. There is evidence to support the use of DBS in less advanced PD and that it may be appropriate for earlier stages of the disease than for which it is currently used. The improving short and long-term safety profile of DBS makes early application a realistic possibility. Moreover, the medical literature reports that waiting too long to use DBS, may be associated with a significantly lessened response. Given the young age of this patient, his rapidly progressive disease, current use of an extremely high dose of medication, and presence of significant fluctuations despite very frequent dosing, DBS is 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The representative of an enrollee has requested the Novo-TTF device for treatment of the enrollees medical condition.  Three physician reviewers found that the Novo-TTF is a novel portable medical device that generates low-intensity alternating electric fields, that was approved by the U.S. Food and Drug Administration for use in the treatment of glioblastoma..  In the study by Stupp and colleagues, 237 patients with recurrent glioblastoma were randomized either to chemotherapy or Novo-TTF therapy.  There was no difference seen in overall survival between the chemotherapy group and the Novo-TTF group.  However, there was noted to be significantly less toxicity in the Novo-TTF group.  All told, the Novo-TTF device was likely to have been more effective than other treatment options. Final Result:  Three reviewers determined that the device at issue was likely to be more beneficial for treatment 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Cytogenic Microarray testing for copy number variation and Preimplantation Genetic Diagnosis testing for evaluation of her medical condition.  Three physician reviewers found that the use of microarray analysis screening in obstetrics has several applications.  The most common application is use in the prenatal post implantation setting.  Recently, it has also been used in certain situations for preimplantation diagnosis.  In this patients case, the limited history provided does not indicate a history of inheritable genetic disorders.  The chart does not give a history of repeatedly failed in vitro fertilization cycles.  Without this technology, this patient would essentially face risks inherently associated with pregnancy similar to that of any other patient of the same age with a spontaneous conception.  At this time, the superior efficacy of the services at issue has not been established. Final Result: Three 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 obstetrics and gynecology 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 a 24-week treatment duration with Harvoni for treatment of the enrollees hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommends several options with similar efficacy for patients such as in this case with compensated cirrhosis and HCV genotype 4 infection in whom prior treatment has failed. Per AASLD/IDSA guidelines the options include daily fixed-dose combination of (Harvoni) ledipasvir/sofosbuvir for 12 weeks, daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir and weight-based ribavirin for 12 weeks, daily sofosbuvir for 12 weeks and daily weight-based ribavirin plus weekly peginterferon for 12 weeks and daily sofosbuvir and weight-based ribavirin for 24 weeks. With specific reference to the Harvoni regimen proposed In the SYNERGY trial, 20 patients with HCV genotype 4 infection were treated with ledipasvir/sofosbuvir for 12 weeks. Of these patients, 40% were treatment experienced and 40% had advanced fibrosis. Preliminary data demonstrate efficacy, with 95% achieving [sustained virologic response at 12 weeks] SVR12 based on an intention-to-treat analysis. As such, AASLD/IDSA guidelines support a 12-week Harvoni course in this clinical setting. All told, the requested medication duration is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication duration 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 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 medical device (Willow Curve) and a referral to an orthopedic specialist for treatment of his shoulder pain.   Findings:  The physician reviewer found that the requested medical device, Willow Curve, is not medically necessary for treatment of the patients medical condition. The Willow Curve is a device which emits photonic and thermal kinetic energies. The efficacy of this device beyond placebo effect is not supported by the medical literature. In sum, the Willow Curve device is not medically necessary in the management of this patients medical condition. However, a referral to an orthopedic specialist is medically necessary for evaluation of the patients medical condition. An orthopedic specialist is clinically indicated to clarify the causes for the patients shoulder pain so treatment protocols can then be determined. All told, the request for a medical device (Willow Curve) is not medically necessary; however the request for a referral to an orthopedic specialist is medically necessary for treatment of the patients shoulder pain.  Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 the VPAP adaptive servo ventilation (ASV) machine and supplies for treatment of his sleep apnea.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the services at issue. Patients with complex sleep apnea have episodes of central apneas and obstructive apneas. The obstructive events apneas/hypopneas are treated with positive pressure ventilation (CPAP or BiPAP) and then an underlying central apnea is present that must be treated with support for ventilation. The ASV provides pressure support for the central apneas and also treats the obstructive events. In this case, the VPAP-ASV machine is indicated for this patient. Based on the documentation submitted for review, the VPAP-ASV machine and supplies provided forward were and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were and 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 pulmonary disease 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 24 weeks for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. The patient has chronic hepatitis C and has an advanced stage disease as he has progressed to cirrhosis. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) national guidelines that set the standard of care in managing and treating patients with HCV state the following Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. Based on available resources, immediate treatment should be prioritized as necessary so that patients at high risk for liver-related complications and severe extrahepatic hepatitis C complications are given high priority. This patient has hepatitis C genotype 1, is treatment experienced having failed other medications and has evidence of cirrhosis. Hence, per the national guidelines, this patient should be treated with Harvoni for 24 weeks. Based on the support per national guidelines and peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical and lumbar epidural steroid injections for treatment of his medical condition. Findings:  The physician reviewer found that the request for cervical and lumbar epidural steroid injections are not medically necessary. In this case, the patient presents with chronic low back and neck pain. Based on the clinical documentation submitted for review, the patients pain is primarily located in the neck and low back without signs of radiculopathy. There is support in the medical literature for the use of epidural steroid injections in radiculitis from disc herniation and spinal stenosis. However, without documented radiculopathy or radiculitis, the use of epidural steroid injections is not clinically indicated. In addition, physical therapy was noted to be tried, however the patients response to the therapy is unknown. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.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 anesthesiology and pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery to set and straighten her leg for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient is a paraplegic with no lower extremity sensation or power.  She sustained a fracture.  She has no pain, and has returned to normal functional activity.  Surgical treatment of this fracture is not indicated based on pain or function.  Contraindications would include the lack of lower extremity function and osteopenia which would place the patient at high risk for delayed fracture healing and nonunion.  All told, the requested surgery to set and straighten the left leg is not medically indicated for the treatment of this patient.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: 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 patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. According to the literature, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies. The breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 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

Criteria/Case Nature of Statutory Summary: An enrollee has requested a wearable cardiac defibrillator (Zoll LifeVest) for treatment of her medical condition. Findings:  The physician reviewer found that based on the records provided, this patient had a newly recognized cardiomyopathy for which medical therapy was initiated.  In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest.  Placement of a prophylactic defibrillator is not recommended until a period of time greater than 90 days where continued left ventricular dysfunction (ejection fraction less than or equal to 35%) is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator before this time has not been demonstrated to improve outcome.  All told, the wearable cardiac defibrillator provided was not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the device at issue was 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 cardiovascular disease 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.