Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested sensory integration and praxis therapy for treatment of the enrollees medical condition.  Findings:  Three physician reviewers found that sensory integration and praxis therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Sensory integration therapy has a robust medical literature as to its long-term value.  A meta-analysis of 27 medical journal articles concluded that sensory integration therapy is effective for the developmentally disabled child. In addition, researchers reported significant success of a sensory integrative program for improving sensory-motor function in developmentally delayed children in a well-controlled study. Given the above, the requested therapy is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested therapy is 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 pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing.  One reviewer is board certified in pediatrics and is actively practicing. One reviewer is board certified in neurology with special qualification in child neurology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for 24 weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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. Per guidelines, the alternative regimen for genotype 3 interferon-ineligible patients is daily sofosbuvir and weight-based ribavirin for 24 weeks. More recently, AASLD/IDSA recommendations for treatment of patients in this clinical setting has shifted to the following: for treatment-naive patients with HCV genotype 3 infection the recommended regimen is daily daclatasvir and sofosbuvir for 12 weeks (no cirrhosis) or 24 weeks with or without weight-based ribavirin (cirrhosis) or daily sofosbuvir and weight-based ribavirin plus weekly peginterferon for 12 weeks is recommended for interferon-eligible patients. In the absence of demonstrated interferon-ineligibility or intolerance to daclatasvir, the 24-week course of Sovaldi treatment is not the highest-rated brief-duration option recommended by AASLD/IDSA, and thus is not medically necessary. For the reasons provided, the requested medication is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The 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 computed tomography (CT) angiogram of the heart for evaluation of her medical condition.   Findings:  Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. Most recently, the PROMISE trial found no clear advantage for coronary CTA in low to intermediate risk patient groups. In addition, the American College of Cardiology Foundation guidelines suggest as a class I recommendation the use of standard exercise stress testing if the patient is able to exercise, or stress testing with stress-echo or nuclear imaging if the patient is unable to exercise or has an abnormal baseline ECG. Standard treadmill or nuclear stress imaging in the low to intermediate risk groups is a class I recommendation. Therefore, based on current guidelines, the request for CT angiogram of the heart is not 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 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that pursuant 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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined 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 IgG food sensitivity testing for evaluation of her medical condition. Findings:  Three physician reviewers found that the current National Institutes of Health National Institute of Allergy and Infectious Disease expert panel states that IgG food testing is not validated. In addition, the Joint Task Force on Practice Parameters for the Allergy and Immunology also state that IgG food testing is not validated. Therefore, IgG food testing is not the standard of care in the medical community. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the testing at issue was 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 internal medicine and allergy and immunology and is actively practicing. One reviewer is board certified in internal medicine and allergy and immunology with sub-specialty certification in rheumatology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. This guideline recommendation is 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. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis brings advantages to providers in the interpretation of mammograms.  These advantages relate to the ability of providers to often separate architectural distortion from dense glandular breast tissue or scar. Thus, the addition of tomosynthesis to the usual two-dimensional (2D) mammographic images was likely of more benefit to the patient than if the mammogram had been done with 2D imaging only.    Final Result: Two reviewers determined that the diagnostic procedure 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar and cervical trigger point injections for treatment of her medical condition.  The physician reviewer found that the request for lumbar and cervical trigger point injections is not medically necessary in this clinical setting. The patient presents with a number of medical problems and complaints. However, there is a lack of documentation of previous treatments or therapies tried and failed. In addition, the medical literature indicates that the trigger point is a focus of hyperirritability in the muscle, that when compressed, is locally tender, and if sensitized, gives rise to referred pain and tenderness. Furthermore the medical literature indicates that the criteria for trigger points include localized spontaneous pain, spontaneous pain or altered sensations in the expected referred area for a given target area, a taut, palpable band in an accessible muscle, exquisite localized tenderness in a precise point along the taut band and a certain degree of reduced range of movement when measurable. In this case, there are no documented palpable points, or previous therapies tried and failed. For the reasons provided, the requested services are not medically necessary for treatment of the patients medical condition.  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 anesthesiology and pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Daklinza, Sovaldi, and weight-based ribavirin 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) for patients with HCV genotype 3 infections with cirrhosis, in whom prior treatment with sofosbuvir and ribavirin has failed the recommended regimens include two treatment options. Daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 24 with weight-based ribavirin for interferon ineligible patients and daily sofosbuvir (Sovaldi) and weight-based ribavirin plus weekly peginterferon for 12 weeks for interferon ineligible patients. In the ALLY-3 study, seven patients previously treated with sofosbuvir-containing regimens were retreated with daclatasvir and sofosbuvir for 12 weeks. Of these patients, 5 (71%) achieved a sustained virologic response (SVR) at 12 weeks. Based on these limited data, 12 weeks of daclatasvir and sofosbuvir is likely to be insufficient, and extending the duration to 24 weeks of therapy and adding weight-based ribavirin is recommended. HCV treatment is medically necessary in this clinical setting. Although the patients records do not support interferon-ineligibility, the two AASLD/IDSA guidelines are equally rated. Moreover, the Daklinza-containing regimen is likely to be better tolerated and as such, the requested medications are medically necessary.  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 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 support Harvoni for treatment-naive patients with hepatitis C, genotype 1 infection.  Patients with viral load of less than 6,000,000 IU/mL can be treated with Harvoni for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, the requested 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: 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:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis allows radiologists to separate architectural distortion or mass from normal, dense glandular breast tissue.  This has resulted in a decrease in callbacks and increase in detection of small cancers.  Based on the medical literature, the addition of breast tomosynthesis to two-dimensional mammography was likely to be more beneficial to the patient than two-dimensional mammography alone.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing.  All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. These guideline recommendations are based on multiple randomized clinical trials. AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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 Northera for treatment of his medical condition Findings:  The physician reviewer found that Northera is a recently released medication to treat orthostatic hypotension, and neurogenic orthostatic hypotension. However, midodrine and fludrocortisone are also very effective agents for treatment of neurogenic orthostatic hypotension. There is a lack of evidence that Northera is more effective than midodrine or fludrocortisone. In sum, the medical necessity for Northera has not been established.  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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Tomosynthesis brings significant advantages to the interpretation of digital mammograms. In particular, tomosynthesis is associated with a decrease in callbacks and increase in detection of small cancers. It is of particular value in patients with extremely dense or heterogeneously dense tissue. As such, the breast tomosynthesis at issue was of greater value than had a digital mammogram been conducted with only two-dimensional technique. Final Result: Three reviewers determined that the diagnostic procedure 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 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.