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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections for treatment of her medical condition.   Findings:  The physician reviewer found that per the evidence-based guidelines, the requested Orthovisc injections are not medically necessary in this patients case. The American Academy of Orthopedic Surgeons in Treatment of Osteoarthritis of the Knee Evidence-based guidelines, recommendation #9 states: We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. The strength of this recommendation is strong. The evidence is based on two or more high strength studies with consistent findings for recommending for or against the intervention.  A strong recommendation means that the quality of the supporting evidence is high. The implication is that practitioners should follow a strong recommendation unless clear and compelling rationale for an alternate approach is present. Based upon recent literature, evidence-based guidelines no longer support viscosupplementation (Orthovisc injections) for osteoarthritis of the knees.  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: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested Familial Adenomatous Polyposis (FAP) and/or Lynch Syndrome gene testing for evaluation of her medical condition. Findings:  Two physician reviewers found that the requested FAP and Lynch Syndrome gene testing is not likely to be more effective for this patient than other available options. This patient does not meet the definition of high risk colorectal cancer syndromes according to the National Comprehensive Cancer Network (NCCN) guidelines. She also does not meet Amsterdam or Bethesda criteria. Thus, the requested gene testing is not likely to be more beneficial than her current standard therapy of increased surveillance with colonoscopy. Final Result: Two reviewers determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical necessity for Norco has not been established. According to Lee and colleagues Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care complementary and integrative medicine (ACT-CIM) therapies allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe and cost-effective. In this case, the patient presents with chronic pain lower back pain. There is a lack of documentation demonstrating that the patient has trialed behavioral therapy for his pain. In addition, not all non-opioid treatment options have been utilized. Given the above, the requested medication 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 physician reviewer is board certified in anesthesiology with sub-certification in 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: 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 per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Medical studies and peer reviewed literature support the use of tomosynthesis in this clinical setting.  For these reasons, tomosynthesis to screen this patient for breast cancer was likely to be more beneficial than any available standard therapy.  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 a sleep study for evaluation of the enrollees sleep apnea. Findings:  The physician reviewer found that in terms of current medical literature and the standards of practice, a sleep study was not medically necessary in evaluation of this patients medical condition. Standards of practice require adequate pre-test documentation, which is lacking in this case., Further, per the post-test clinical documentation, the patient had classic signs and symptoms to suggest the presence of obstructive sleep apnea (OSA). As a result, there was no compelling reason supported by the literature to support the need for attended testing. Moreover, the patients records did not indicate that the patient had any contraindications to home sleep testing.  All told, the services at issue were not medically necessary in evaluation of this patients sleep apnea. Final Result: The reviewer determined that the services at issue were not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications:  The reviewer is board certified in neurology with sub-specialty certification in sleep 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. The problem of evaluating dense breasts or suspicious calcifications is a significant issue in the field of mammography. In this clinical setting, the tomosynthesis was more beneficial than breast sonography as a screening tool.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Given the support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. The guidelines classify patients with diabetes mellitus as high risk for fast progression. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. Per the submitted records, this patient is ineligible for the alternative for genotype 1a due to depression, which can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy. 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 physician reviewer is board certified in internal medicine with sub-certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found  the American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the exam had been done with two dimensional technique alone. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation for treatment of his medical condition. Findings:  Two physician reviewers found that radiofrequency ablation is likely to be more beneficial for treatment of the enrollees medical condition. The peer-reviewed literature supports the efficacy of radiofrequency ablation in the treatment of chronic spinal pain due to facet pathology as long as the patients are appropriately selected. Tzaan and Tasker performed a retrospective study to assess the value of percutaneous radiofrequency facet rhizotomy. The authors concluded that the procedure is simple and safe in patients with disabling spinal pain that fail to respond to conservative treatment. Per the medical records submitted, imaging is significant for multi-level spondylosis. The physical exam is also significant for facet mediated pain. The provider documents that the patient has failed conservative treatment. In addition, the records document 90% pain relief with diagnostic medial branch blocks. Therefore, radiofrequency ablation is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested services are 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 anesthesiology with sub-specialty certification in pain medicine 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 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. Per guidelines, genotype 1 patients who have failed Sovaldi/ribavirin therapy should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure (Osinusi, et al; Reddy, et al). AASLD guidelines cite data showing decreased 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 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 Daklinza for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions, and patients with cirrhosis are high priority for therapy. Per the guidelines, non-cirrhotic treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. This recommendation is based on multiple randomized clinical trials, and the guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients (Zeuzem, et al; Lawitz, et al; Jacobson, et al). According to the guidelines, Sovaldi and Daklinza should only be used when there is a medical contraindication to ribavirin. While treatment of this patients hepatitis C is medically necessary, there is no documentation to show that he has a contraindication to ribavirin. For these reasons, treatment with Sovaldi and Daklinza for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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/Qualification:  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 psychiatric residential treatment center services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the residential treatment center services provided were initially medically necessary for treatment of the patients medical condition, but not thereafter. The patient was not a danger to herself or others. She was not engaged in treatment, had cravings, and had made the statement that she would return to drinking, representing a risk given her level of defensiveness and lack of insight and judgment at that point in her treatment. Family therapy was in the early stages as well, again, given the patients lack of engagement in the therapeutic processes. At this point in time returning her to her environment may in fact have undermined treatment as she had not yet begun to develop interest or coping strategies. The patient still required residential level of care. However, she was showing the development of coping strategies and engagement in treatment, both individually and in family therapy. She was utilizing mechanisms such as walking to discharge anxiety and had been working on her accountability letter. Thus, subsequently she could have continued treatment at a lower level of care. Given the above, a portion of services at issue were medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that a portion of the services at issue were 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 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 Zoloft for treatment of her behavioral health condition. Findings: The physician reviewer found that Zoloft is a serotonergic enhancing medication approved by the U.S. Food and Drug Administration (FDA). Zoloft remains just one of two medicines today approved by the FDA to treat PTSD. The generic name for Zoloft is sertraline. There is potential for bioavailability variance when a generic medication replaces a brand name. On rare occasions, the possibility exists that differences in potency may underlie adverse changes in clinical status (Sussman). In this case, the patient is treated with a medication FDA approved for her two psychiatric diagnoses. She previously decompensated when prescribed generic sertraline. The medical record indicates that this patient has intolerance to Depakote and Zoloft generics. Therefore, brand name Zoloft is medically necessary and safe, appropriate and reasonably expected to both improve the patients condition and prevent an exacerbation of the illness burden.    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 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.