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 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. 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 AASLD/IDSA guidelines cite data showing decreased 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested orthodontic services for treatment of the enrollees medical condition. Findings: The physician reviewer found that the review of the submitted clinical documentation fails to demonstrate the medically necessary for the services at issue. In the setting of mixed dentition, there is a lack of support in the dental literature demonstrating benefit to interceptive treatment where the patient is still expected to have significant growth which will somewhat mitigate the dental crowding observed as described in this case. In addition, the patients score on the Handicapping Labio-lingual Deviation (HLD) index was well below the accepted minimum score required to indicate a severe handicapping malocclusion. Given the clinical documentation demonstrating minimal crowding of the teeth, the orthodontic services at issue were not indicated for this patient.  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 physician reviewer is board certified in dentistry 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 the Afirma Gene Expression Classifier for evaluation of her medical condition. Findings: Two physician reviewers found that while a FNA biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of FNA biopsy results are considered to be indeterminate. Until recently, the only way to establish whether the nodule was in fact thyroid cancer was via surgical excision even though the majority of the cases turn out to be benign. The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on FNA biopsy, thereby decreasing the need for unnecessary surgeries. Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Given the above, the Afirma Gene Expression Classifier 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 testing 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology and metabolism and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.  Findings:  Three physician reviewers found that due to the advantages tomosynthesis provides to radiologists interpreting mammograms, the American College of Radiology (ACR) has urged the technique be removed from the investigational category. The advantages of tomosynthesis are due to the tomographic nature of the technique allowing radiologists to separate dense glandular tissue from underlying mass/architectural distortion. There is sufficient literature to support an associated decrease in callbacks and increase in detection of small cancers when tomosynthesis is used as part of the screening process. This has been shown to be particularly valuable in patients with heterogeneously dense or extremely dense tissue. For these reasons, it is likely that the addition of tomosynthesis to the usual two-dimensional (2D) mammogram views was likely of more benefit to this patient than had the exam been done with 2D technique only.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested platelet rich plasma injections for treatment of his medical condition.  Findings:  Three physician reviewers found that platelet rich plasma therapy has not been proven to be an effective treatment for chondral injury, chondral pathology, arthropathy, tendinopathy or bursitis affecting. There is a lack of high-grade clinical studies to support the efficacy of the autologous platelet rich plasma injections, specifically in the setting of any knee condition, including patellofemoral, patellar, or tibiofemoral pathology. There is a lack of evidence that it favorably modifies the clinical course of any musculoskeletal condition. Multiple reviews have concluded that there is a lack of high-grade evidence to support the efficacy of this intervention. Given the lack of high quality medical literature establishing the effectiveness of platelet rich plasma, the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in physical medicine and rehabilitation 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:   The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not in withdrawals  and  was medically stable.   There was no evidence to suggest that treatment at a lower level of care would have resulted in harm to the patient.  The patient required redirection but was beginning to develop insight into areas requiring work.  He needed ongoing treatment to continue to work on relapse prevention and coping skills, and receive necessary support.  However, he did not require treatment in a 24-hour setting for these purposes.  The patient could have continued this at a lower level of care such partial hospitalization program or intensive outpatient program.  All told, residential treatment center services were not medically indicated for the treatment of this patient. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiation therapy for treatment of his medical condition. Findings: Three physician reviewers found that stereotactic body radiotherapy is an accepted standard therapy for patients with early stage lung cancer. Studies have shown it is associated with a local control rate of greater than 90%, which is comparable to surgical outcomes. Furthermore, stereotactic radiotherapy is well documented to be superior to conventional radiation treatment with standard fractionation.  The patients decision to not undergo surgery is acceptable as many patients do not want to undergo an invasive procedure, or undergo the risks of general anesthesia. The alternative therapy in such a case is a non-invasive method of treatment of the cancer using stereotactic radiation. Therefore, the requested stereotactic body radiation therapy is likely to be more beneficial for the treatment of the patients condition than any standard therapy.   Final Result: Three 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 physician reviewers are board certified in radiation 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 skilled nursing facility services for the treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this patients case, she sustained ischemic stroke.  She underwent extensive inpatient rehabilitation at the acute inpatient rehabilitation level, as well as the skilled nursing facility level of care.  She made significant functional progress.  As of the date in question, she had progressed to ambulating household distances with a cane at the contact guard assistance level.  Further reconditioning and ongoing rehabilitative management could have been provided at the home and outpatient settings.  The records do not document any issues that would indicate that the patients rehabilitative needs could not have been safely provided at a lower level of care in the home with supervision to custodial level assistance and community-based rehabilitative services.  There are no documented ongoing skilled nursing needs requiring ongoing inpatient care in the available records.  All told, the skilled nursing facility services at issue were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her 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. This patient should be considered treatment-naive due to lack of any complete prior treatment with peg-interferon/ribavirin.  Per 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. This patient should be considered ineligible for Viekira/ribavirin due to side effects with ribavirin in the past.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested  a positron emission tomography (PET) scan for evaluation of her medical condition. Findings: Three physician reviewers found that the current medical evidence supports the requested services in this clinical setting.  It is important to have a sense of the activity of the disease before initiating relatively invasive and potentially harmful immunosuppressive or biological drugs.  Conventional laboratory indicators are non-specific and are often misleading.  Currently, PET scanning is the optimal modality in assessing activity.  Other modalities such as angiography, magnetic resonance imaging (MRI), and ultrasound are more geared to display anatomy.  In sum, the requested PET scan is likely to be more efficacious than other methods of evaluating this patient.Final Result: Three reviewers determined that the requested services are 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 physician 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 bronchial thermoplasty for treatment of his medical condition.  Findings: Two physician reviewers found that initial trials of bronchial thermoplasty have demonstrated improved symptom control after the procedure was completed. The AIR trial by Cox and colleagues examined 112 subjects with moderated to severe asthma and demonstrated improved control over the course of the one year follow-up. The RISA study by Pavord and colleagues examined the safety of thermoplasty and found short term worsening in symptoms, but evidence of improved long term control of asthma. Finally, the AIR2 trial by Castro and colleagues compared thermoplasty with a sham procedure and followed the patients out for 12 months as well. The patients in this study had milder asthma when compared with the AIR and RISA study, with far fewer on oral corticosteroids. The study found that the thermoplasty group had fewer exacerbations and improved quality of life when compared to the sham group. Neither the AIR nor RISA trials demographics indicate whether patients were on medications other than steroids (inhaled and/or oral) and bronchodilators. The AIR2 trial on the other hand had 30% of the enrolled patients in the thermoplasty group on other controlling agents and fewer patients on oral corticosteroids. Thus, the data supports the short and long term benefits of bronchial thermoplasty. In this case, bronchial thermoplasty is indicated for this patient. He is on a very aggressive regimen of bronchodilators, is prednisone responsive and is not a candidate for omalizumab as he does not have allergic disease. There is little left in the standard armamentarium to control his described refractory symptoms. Given that all these interventions have not controlled his asthma, bronchial thermoplasty 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: One reviewer is board certified in orthopedic surgery and is actively practicing. Two physician reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni for 12 weeks 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 physician 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.