Persius/hicric huggingface dataset:
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 her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines 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 1b patients should be treated with Viekira Pak for 12 weeks. This recommendation is based on multiple high-quality clinical trials and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment for Viekira Pak is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency ablation of the bilateral sacroiliac joints for treatment of her medical condition.   Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The provider reported that the patient experienced improvement from prior radiofrequency ablation.  However, the duration was not mentioned.  The patient stated it lasted a specific length of time, but this is not corroborated in the office visits.  A request for fusion of the sacroiliac joint was made by the provider.  Furthermore, while the patient states she underwent conservative care, it is unclear this was directed to the sacroiliac joint.  Per the medical literature, radiofrequency ablation is done after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage.  This was not included in the documentation available for review.  Therefore, the superior effectiveness of radiofrequency ablation of the bilateral sacroiliac joints has not been established. Final Result:  Two reviewers determined that the requested services are 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 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 prophylactic mastectomy of the left breast and bilateral breast reconstruction utilizing fat transfer microsurgery for treatment of her medical condition.  Findings:  The physician reviewer found that with the patient's personal history of breast cancer and family history of breast cancer, she is at increased risk of breast cancer. This is supported by the genetic counseling recommendation for genetic testing. A prophylactic mastectomy is medically necessary under these circumstances. In sum, a prophylactic mastectomy for this patient is consistent with standard of care. In addition, due to complications of the original breast reconstruction, the request for bilateral breast reconstruction utilizing fat transfer microsurgery (autologous breast reconstruction) is indicated. The most common type of autologous reconstruction is with the use of the abdominal soft tissue. This can be in the form of a transverse rectus abdominis myocutaneous (TRAM) flap or deep inferior epigastric artery perforator (DIEP) flap, which is meant by microsurgical fat transfer. A DIEP flap preserves the abdominal musculature of the TRAM flap and uses the skin and fat of the abdomen with a microsurgical transfer. For the reasons provided, prophylactic mastectomy of the left breast and bilateral breast reconstruction utilizing fat transfer microsurgery are both 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested skilled nursing facility services for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility services has not been established. In this case, the patient was functioning at a high level in physical therapy. Further intensive skilled physical therapy services, at the skilled nursing facility level, were not medically necessary at that time. He did not show a need for speech therapy or skilled nursing services. His functional level for self-cares was not described in detail. Overall he showed progress on occupational therapy throughout his stay. For the reasons provided, the skilled nursing facility services in question were not medically necessary for treatment of the patients medical condition.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Egrifta (tesamorelin for injection) for treatment of his medical condition.   The physian reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested medication. There is a lack of support in the medical literature for the requested medication.  At least two studies have not indicated a change in glucose levels with tesamorelin therapy. There is also a lack of evidence to support that the patients hyperlipidemia or hypertension would be improved. Cardiovascular disease, as measured by coronary artery calcification scores was found to correlate with hepatic fat accumulation in one paper ; but there is a lack of data about the impact of the proposed therapy on cardiovascular disease and outcomes. Moreover, there is a lack of evidence that this therapy would provide significant benefits to the patient. Data from published studies indicate his metabolic conditions would not be improved and there is a lack of evidence regarding long-term cardiovascular disease benefits. For the reasons provided, the request for Egrifta (tesamorelin for injection) is not medically necessary. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in infectious diseases 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 lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  A discogram is noted to be positive for concordant pain.  However, there is no evidence of spondylolisthesis, instability on flexion/extension films at the level of the herniation.  The documentation also does not indicate if any iatrogenic instability will be created intraoperatively that would necessitate a fusion.  The medical evidence is insufficient to support lumbar fusion being more effective than nonsurgical treatments in patients with and without prior surgery.  The evidence for lumbar spinal fusion does not conclusively demonstrate short-term or long-term benefits compared with nonsurgical treatment.  The documentation provided does not indicate any neurologic deficit in the left lower extremity corroborating the MRI findings of a herniated disc.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested lumbar spinal fusion is not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested home health aide services during the evenings and weekends for treatment of her medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient presents with ALS and is in hospice. She has chosen to receive hospice care in the home setting. The medical literature notes that intensive home hospice services can be necessary to meet the goals of the patient. In the present case the patient is dependent for self-care and functional mobility which requires assistance twice daily to ensure she remains clean and comfortable. A study found that respiratory symptoms are a significant problem for ALS patients in hospice. Patient positioning is an important part of managing these symptoms and having home health aides visit twice daily will improve the patients positioning. Evidence supports that the patient will benefit from home health aide services twice daily.  In sum, home health aide services during the evenings and weekends, twice daily is medically necessary in this clinical setting.  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 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 Harvoni for treatment of her hepatitis C.   Findings:  The physician reviewer found that according to 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 conditions.  For treatment-naive patients with hepatitis C, genotype 6 infection, the guidelines recommend Harvoni.  For these reasons, Harvoni 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: The parent of an enrollee has requested applied behavioral analysis (ABA) therapy at the frequency of 120 hours per month, including 12 hours per month of supervision for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based on the documentation submitted for review, the patient has a diagnosis of autism. Researchers demonstrated that ABA therapy is medically necessary for children diagnosed with autism spectrum disorder (ASD). Researchers also showed that those with optimal outcome with a previous diagnosis of ASD had earlier and more intense ABA therapy. The literature  included primarily 30 to 40 hours per week of ABA. At this time there is no evidence that this patient is ready for a decrease in services. He is progressing with his current level and needs to continue at 120 hours per month of ABA with 12 hours per month of supervision. All told, the requested services are medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in child neurology 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:  The parent of an enrollee has requested genetic testing for evaluation of the enrollees medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The panel that was ordered includes evaluation of conditions associated with aortic pathology.  The patient has a documented normal aorta by echocardiogram.  In the absence of aortic or other vascular abnormality, gene testing for conditions associated with aortic dilation, aneurysm and dissection is not indicated.  Based on the submitted medical records, the superior efficacy of the requested genetic testing has not been established.   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: One reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care medicine and is actively practicing. One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in pediatrics and clinical genetics and is 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 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, 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 1b patients are appropriate for treatment with a 12-week course of Viekira Pak. This recommendation is based on multiple high-quality clinical trials. In addition, 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 also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment for Viekira Pak is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested emergency room services provided on an emergent basis. Findings:  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 upper respiratory symptoms with a fever. The patient denied any shortness of breath or vomiting. She was noted to be in no acute distress. Her temperature was elevated, which resolved with administration of oral acetaminophen. No radiologic studies or laboratory testing were performed. While parental concerns were noted over the patients persistent fever, the patients symptoms were not sudden or acute in onset. Moreover, the patient was not in acute distress and there was nothing in the patients history, physical exam, or ER evaluation that indicated any emergent or even urgent medical condition. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe the patient was suffering from a serious medical condition that required immediate medical attention. In sum, the patient was not experiencing 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 care. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus. Findings:  The physician reviewer 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 (HCV) genotype 2. Per the guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The proposed combination therapy with Sovaldi and ribavirin has been approved by the FDA based upon a large trial involving genotype 2 and 3 patients. This regimen has also been endorsed by the AASLD/IDSA in their recent guidelines for the treatment of HCV patients. The initial phase three studies (FISSION, FUSION and POSITRON) demonstrated that the Sovaldi regimen was well-tolerated, safe and efficacious. As such, Sovaldi and ribavirin is medically necessary for treatment of the patients medical condition. 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.