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 (HCV). Findings: The physician reviewer found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, there is only one treatment option for this patient in whom previous sofosbuvir plus ribavirin with or without peginterferon treatment has failed, and has no cirrhosis. Daily fixed-dose combination of ledipavir (90 mg)/sofosbuvir (400 mg) with weight-based ribavirin for 12 weeks is recommended for patients without cirrhosis is recommended as a Class IIb, Level C rating. AASLD/IDSA states To date, clinical experience and trial data on the retreatment of such patients are very limited. However, retreatment after a sofosbuvir-containing treatment failure with a second course of treatment using sofosbuvir plus new agents, or retreatment with the same sofosbuvir-based regimen has been reported. There is insufficient data available at this time regarding the treatment of Technivie in this patients clinical setting. Retreatment with ledipasvir/sofosbuvir in patients with HCV genotype 1 infection, with or without cirrhosis, in whom a sofosbuvir-containing regimen failed, has been evaluated in two small pilot studies utilizing ledipasvir/sofosbuvir for 12 weeks. With prior failures of 24 weeks of sofosbuvir plus ribavirin, high sustained virologic response (SVR) rates were noted when patients were retreated with ledipasvir/sofosbuvir for 12 weeks. (Osinusi, et al) Ledipasvir/sofosbuvir plus ribavirin has also been evaluated in subjects in whom prior treatment with sofosbuvir plus peginterferon and ribavirin or sofosbuvir and ribavirin failed. In this study of 51 patients, retreatment with ledipasvir/sofosbuvir plus ribavirin for 12 weeks led to SVR at 12 weeks in 100% of 50 patients with HCV genotype 1 infection; 1 virologic failure was observed in a patient determined to have HCV genotype 3 infection prior to retreatment (Wyles, et al). As such, the medical necessity for Harvoni has been established 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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a water circulating cold pad with pump for treatment of her symptoms related to her right knee surgery.   Findings:  Three physician reviewers found that there is insufficient evidence in the peer-reviewed literature to support cooling devices following non-major orthopedic surgeries. According to researchers, use of a cooling device in patients undergoing routine knee arthroscopy without a history of thromboembolism did not result in thromboprophylaxis (reduced risk of blood clot formation). All told, there is inadequate evidence that the use of cooling devices results in improved clinical outcomes in this setting. Based upon the submitted records and review of the peer-reviewed literature, there is a lack of evidence to support the water circulating cold pad with pump for this patient. As such, the device at issue was not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the device at issue was 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 orthopedic surgery 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 a Permobil F5 Group 4 power chair for treatment of his medical condition. The submitted documentation establishes the medical necessity of the requested Permobil F5 Group 4 power chair. There is sufficient support in the medical literature for the requested equipment. According to researchers, The benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. Power mobility can benefit specific individuals. Determination of who will benefit is a matter of clinical judgment more than of adherence to criteria defined by the literature. In this case, the patient has a profound mobility deficit that requires an appropriately fitted power wheelchair. With a power wheelchair he is able to achieve functional mobility. The wheelchair must be properly fitted to reduce risk of pressure ulcers and other complications of spending long periods in a single position. Researchers performed a systematic review and concluded that standing 60 minutes daily can improve range of motion and bone mineral density. Thus, the requested equipment is indicated for this patient to achieve functional mobility and to reduce complications of quadriplegia. Therefore, based on the clinical documentation submitted, the Permobil F5 Group 4 power chair is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ribapak and Technivie 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.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks.  The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Ribapak and Technivie are medically indicated for the treatment of this patient. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a consultation with a rheumatologist for the 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 has been diagnosed with achalasia and continues to experience esophageal dysmotility.  Although over 90% of patients with scleroderma have esophageal dysmotility, with only half of these patients experiencing symptoms, it would be unusual for these to be the only presenting symptoms.  Gastrointestinal symptoms can range from esophageal hypomotility, chronic gastroesophageal reflux, with subsequent chronic esophagitis and stricture formation, Barretts esophagus, and pulmonary microaspiration.  To diagnose scleroderma, there are three hallmarks: fibrosis of the skin and/or internal organs, production of specific autoantibodies, and evidence of vasculopathy.  If the skin thickening of the fingers extends proximal to the metacarpophalangeal joints, the patient is to be classified as having systemic sclerosis.  If those skin findings are not present, then there are other additive clinical findings which may be used.  These include skin thickening of the fingers, fingertip lesions, telangiectasia, abnormal nailfold capillaries, interstitial lung disease or pulmonary arterial hypertension, Raynauds phenomenon, and systemic sclerosis-related autoantibodies. In this case, the medical records fail to demonstrate any of the clinical findings used to make the diagnosis of scleroderma.  As such, the request for consultation with a rheumatologist is not medically necessary.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested endoscopic sinus surgery and nasal septum reconstruction for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services.  This patient has been treated for recurrent sinus infections.  Per the records, he has been treated with antibiotics and steroids.  He has tried several medical therapies and continues to be symptomatic.  He has undergone formal allergy evaluation as well, with negative findings. As such, there is support for the requested endoscopic sinus surgery, which is designed to improve sinus drainage with the goal of reducing acute flares of symptoms and need for antibiotics.  However, the medical records do not support nasal septum reconstruction in this patients case.  The documentation does not show that septal deviation is symptomatic.  Nasal septum reconstruction would only be indicated if it resulted in obstruction to access during endoscopic sinus surgery.  All told, the requested endoscopic sinus surgery is medically indicated for the treatment of this patient.  However, the requested nasal septum reconstruction is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that a portion of the requested services is 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 otolaryngology 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.  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.  This patient should be considered ineligible for Viekira/ribavirin due to her medical history, which can be exacerbated by ribavirin. 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 Foundation One gene testing for the evaluation of his medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Despite advances in the treatment of non-small cell lung cancer, the prognosis remains poor, especially with advanced disease.  As this patient lacks a driver mutation, such as KRAS, EGFR, or ALK, newer agents are not available to him.  Molecular profiling, such as Foundation One, identifies novel molecular markers to help guide enrollment in clinical trials, many of which require this prior to enrollment.  All told, the Foundation One gene test was likely to have been superior over other methods of evaluating this patient.  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 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: 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 that the submitted documentation supports the services at issue in this clinical setting.  According to the medical literature, 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.  The medical literature noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  The medical literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluation.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: 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of his hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. The recommendation applies regardless of fibrosis stage or viral load.  For these reasons, Viekira Pak 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 monitored anesthesia care for 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.  The patient did not present with a significant history that would require monitored anesthesia care.  The standard of care for monitored anesthesia care for a minimally invasive procedure is airway difficulty, large fluid shifts and comorbid conditions that would put the patient at risk during the procedure.  In this case, there is no documentation of comorbid conditions that would place the patient at risk for complications requiring the need for monitored anesthesia care.  All told, monitored anesthesia care was 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 anesthesiology 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 computed tomography (CT) of the heart without dye with quantitative evaluation of coronary calcium for evaluation of her medical condition.  Findings: Two physician reviewers found that the requested services are likely to be more effective for this patient than other available options. There has been growing evidence on the use of coronary artery calcium (CAC) screening in better-studied cohorts of patients and asymptomatic individuals. CAC scoring has an increasingly high level of quality evidence on its role in risk stratification of asymptomatic patients. The accumulating evidence suggests that asymptomatic individuals with an intermediate Framingham risk score (FRS) may be reasonable candidates for coronary heart disease testing using CAC as a potential means of modifying risk prediction and altering therapy. The American College of Cardiology Foundation judged that it may be reasonable to consider use of CAC measurement in intermediate risk patients based on available evidence that demonstrates incremental risk prediction information in this selected patient group. This conclusion was based on the possibility that such patients might be reclassified to a higher risk status based on high CAC score, and subsequent patient management may be modified. Testing using CAC would reclassify many to a higher or lower risk category and improve health outcomes by treating those with asymptomatic coronary atherosclerosis to evidence based medical therapy and those with low risk to careful follow-up. All told, the requested services are likely to be more beneficial for evaluation 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 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 cardiovascular 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.