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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of her chronic hepatitis C virus genotype 3.   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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. Non-cirrhotic treatment-naive genotype 3 patients are recommended to be treated with Sovaldi and Daklinza for 12 weeks. These guideline recommendations are based on the ALLY-3 trial, which demonstrated a 90% cure rate and a 97% cure rate in patients without cirrhosis, such as this patient. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature and clinical guidelines, treatment with Sovaldi and Daklinza for 12 weeks is supported as medically necessary for treatment of this patients hepatitis C virus. Final Result: The reviewer determined that the requested medications 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 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 the LINX reflux management system for treatment of his gastroesophageal reflux disease (GERD) and hiatal hernia.  Two physician reviewers found that currently, there is a paucity of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. An evidence review concluded that the long-term safety and efficacy of LINX  both alone and in comparison to current GERD therapies  remains to be determined. In addition, another best-evidence review concluded that further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments. Adverse events, such as erosion through the esophagus, have also been reported in the period after U.S. Food and Drug Administration (FDA) approval. Given these findings, the requested LINX Reflux Management System is not 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 procedure is 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested services on an emergent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with right lower back, hip and leg pain and rated her pain. However, on physical examination it was noted that the patient appeared in no distress and her vital signs were normal with no history of acute injury. Thus, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested serum adalimumab testing for the amount of adalimumab and antibodies to adalimumab (Prometheus Anser ADA testing) for evaluation of her Crohns disease.  Two physician reviewers found that the use of Anser ADA has not been demonstrated in randomized controlled clinical trials to improve patient outcomes. In this case, Anser ADA was ordered to determine the cause for possible loss of response to Humira and to direct the management of the patients Crohns disease. The test revealed a lack of antibodies and that the drug was present. However, the effectiveness of Anser ADA compared with conventional courses of action remains unproven. Patients being treated with adalimumab may experience loss of response. Loss of response can be due to multiple factors, and the appropriate method for determination of the cause for loss of response is not clear. The American College of Gastroenterology clinical guidelines for management of Crohns disease do not recommend testing for anti-drug antibody during clinical management. All told, the peer-reviewed medical literature does not suggest that the serum adalimumab testing for the amount of adalimumab and antibodies to adalimumab (Prometheus Anser ADA testing) was likely to have been 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgical breast augmentation for treatment of her gender dysphoria. The physician reviewer found that the patient presents with gender dysphoria which is a source of significant adverse effect on her mental health. She has been transitioning from the male-to-female gender over the past four to five years. She has been treated with hormonal therapy without adequate breast development. The patient is well-documented to have gender dysphoria. Currently, her examination and photographs depict a lack of breast development and is more consistent with male anatomy. The surgical concept of breast augmentation in male-to-female transgender patients is well-established and documented within the community of plastic surgeons.  According to Weigert and colleagues, Breast augmentation in male-to-female transsexuals is part of gender reassignment surgery. Hormonal feminization might not be sufficient to induce mammogenesis so many patients seek surgery for their chests to resemble the female gender. The authors further state, Through breast augmentation, the male-to-female transsexual patient improves identification with the female gender and therefore is socially integrated. Regarding results, this study supports breast augmentation in this population. In the case of this patient, medical necessity for breast augmentation surgery has been adequately demonstrated in the medical documentation provided for review. Further, the requested procedure is considered reconstructive in this setting. The patient is well-documented to have gender dysphoria; thus her external anatomy should be more consistent with a female than a male. As the patient has failed hormonal therapy, her abnormal breast structure should be considered the result of a developmental abnormality. The requested surgery is intended to create a normal appearance, as her current appearance is not consistent with an adult female. The surgery would attempt to provide a more normal female appearance and is likely to result in more than a minimal improvement. For the reasons stated above, surgical breast augmentation is medically necessary for treatment of the patients medical condition and considered reconstructive in nature.   Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and considered reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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 Harvoni for eight weeks for treatment of her hepatitis C virus.  Findings:  Three physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C virus genotype 1. As per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. In addition, the requested medication is expected to potentially cure hepatitis C infection and prevent further damage of the liver and progression of the disease process and development of cirrhosis long-term and its potential complications. Therefore, it is medically necessary for this patient to be treated with Harvoni for eight weeks to prevent further development and progression of fibrosis due to ongoing hepatitis C infection and prevent potential complications of advanced liver disease, long-term. Final Result: Three reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing.  Two reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are 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 consultation with a fertility specialist for treatment of her possible egg retrieval and use of a surrogate.  The physician reviewer found that according to Kuohung and Hornstein, Age is an important factor affecting a womans fertility. The decrease in fecundability with aging is likely due to a decline in both the quantity and quality of the oocytes....The likelihood of a fertilized egg implanting is related to the age of the woman who produced the egg. Thus, the percentage of transfers resulting in live births for cycles using embryos from women's own eggs declines as women get older. Moreover, Chung and Paulson state Many women who delay childbearing may face infertility by the time they are ready to become pregnant. Women of advancing reproductive age who wish to delay childbearing may consider methods of fertility preservation, including embryo and oocyte cryopreservation....Success of mature oocyte cryopreservation has improved dramatically over the past decade, and it is no longer considered experimental by the American Society for Reproductive Medicine (ASRM) or American College of Obstetricians and Gynecologists (ACOG). For women who do not have a participating male partner and are not interested in using donor sperm, oocyte cryopreservation is generally the preferred option. In this case, the patient concerned about her potential for fertility and requests expert information about her options. She is not in a partnered relationship, so trying currently for a pregnancy is not an option. Her gynecologist has referred her to a fertility specialist so she can explore the option of egg freezing. The patient is also concerned about whether she can carry a pregnancy and wants to discuss the option of surrogacy. This patient is at a crucial time for cryopreservation, if she chooses to pursue it and she cannot decide about her future options without input from a reproductive technologist. Therefore, the patients request for a consultation with a fertility specialist is medically necessary. 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 obstetrics and gynecology 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 H.P. Acthar Gel for treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The available medical records do not provide documentation that supports a diagnosis of rheumatoid arthritis.  There is no data to support this diagnosis.  There is also no documentation that supports a diagnosis of cytokine deficiency that would potentially preclude the use of a biologic agent.  The available medical records do not provide supporting documentation that the patient has a steroid responsive condition.  All told, the requested H.P. Acthar Gel 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 enrollees medical condition.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in rheumatology 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 Hyalgan injections for treatment of her osteoarthritis. Findings:  The physician reviewer found that the American Academy of Orthopedic Surgeons (AAOS) has changed their policy with regard to viscosupplementation and state that we cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. The medical literature concluded that treatment of knee osteoarthritis with injections of intra-articular hyaluronic acid does not meet CTAF criteria for safety, efficacy and improvement in health outcomes for progression to knee replacement or progression of disease. In addition, the medical literature reported that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. Based upon a review of the literature and AAOS guidelines, the requested Hyalgan injections are not medically necessary for treatment of this patients knee osteoarthritis.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 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. In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area appropriate to the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza, Sovaldi and ribavirin for 24 weeks for treatment of her chronic hepatitis C virus genotype 3a.  Findings: The physician reviewer found that according 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. Per the guidelines, patients with cirrhosis are considered high priority for treatment. Additionally, patients with decompensation are considered interferon ineligible by AASLD/IDSA guidelines. In cirrhotic treatment naive interferon ineligible genotype 3 patients, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 24 weeks. For these reasons, the requested treatment with Sovaldi, Daklinza, and ribavirin for 24 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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 eight weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the requested medication in this clinical setting.  Harvoni has been approved for the treatment of patients with chronic hepatitis C, genotype 1 infection.  The current medical evidence supports Harvoni for eight weeks for this treatment-naive patient with a viral load less than 6,000,000 IU/mL.  Based on the current medical literature, Harvoni for eight weeks 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:  An enrollee has requested for Harvoni for 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested treatment is likely to prevent further development and progression of fibrosis.  All told, Harvoni for 12 weeks 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 enrollees medical condition.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 computed tomography (CT) scan of the brain for evaluation of his medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patients history is not supportive of intracranial pathology presenting with loss of consciousness.  The medical record does not support the potential diagnosis of an unwitnessed seizure.  Neurocardiogenic syncope, cardiac pathology or possibly alcohol intoxication associated loss of consciousness are more likely diagnostic possibilities which would not require intracranial imaging.  All told, the requested CT scan of the brain is not medically necessary for the evaluation of this patient.   Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the enrollees medical condition.  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.