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 eight weeks for treatment of his hepatitis C.  Findings:  Three physician reviewers 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 life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients without cirrhosis who have hepatitis C, genotype 1 infection are recommended to be treated with Harvoni.  Additionally, treatment of patients before they progress to cirrhosis is advantageous.  Based on evidence of safety and efficacy in the published literature, Harvoni for eight weeks is medically indicated for the treatment of this patient. 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: The 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: Overturned 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 have sought immediate medical attention. According to High and colleagues Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe mucocutaneous adverse reactions, most commonly triggered by medications, characterized by fever and extensive necrosis and detachment of the epidermis. SJS and TEN are considered a disease continuum and are distinguished chiefly by severity. Upon review of the submitted medical records, the patient presented with persistent fever despite being on antibiotics, recurrent dehydration and worsening rash thought to be due to medications. Each of these conditions were potentially life threatening and in the absence of immediate medical attention could reasonably be expected to result placing the patients health in serious jeopardy, Therefore, the services met prudent layperson criteria for emergency care. Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Strattera for treatment of his attention deficit hyperactivity disorder (ADHD) and depression.  The physician reviewer found that Strattera is a selective norepinephrine reuptake inhibitor used to treat patients with ADHD. Strattera is a non-stimulant, which distinguishes itself from other common pharmacologic interventions for ADHD. Stimulant medicines, such as methylphenidate and amphetamine-based products remain the gold-standard treatment for ADHD. The stimulants exert their primary effect on the dopamine system. Although contemporary psychiatric practice aims to limit polypharmacy, there is no contraindication to concomitant Strattera and stimulant therapy. However, this patients documentation does not include a psychiatric evaluation, diagnostic assessment, medication history, clinical rating scales or serial progress notes to support an indication for the requested medication. Thus, based on the documentation provided, the requested Strattera is not supported as medically necessary for treatment of this patients ADHD. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested vein surgery for treatment of his symptomatic varicosities. Findings:  The physician reviewer found that overall, the documentation does not support the medical necessity of the requested procedures for treatment of this patients bilateral leg pain. There is no venous duplex provided that demonstrates absence of deep venous obstruction or significant reflux in the veins selected for treatment. The records also do not adequately document that the patient was provided with a prescription for medical grade compression stockings and instructed in their use in a concerted effort to treat conservatively. Thus, the requested vein surgery is not medically necessary for treatment of this 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 vascular 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested implantation of a hypoglossal nerve stimulator for treatment of his obstructive sleep apnea (OSA).  Two physician reviewers found that OSA can have significant effects on both personal and public health. CPAP has demonstrated excellent efficacy for patients with OSA and has long-term adherence rates approaching 50%. Although traditional upper airway surgical procedures target the anatomic component of obstruction, upper airway stimulation tackles the twin goals of improving anatomic and neuromuscular pathology. After decades of trials demonstrating proof of concept of hypoglossal nerve stimulation in a research setting, the results of a large multicenter, prospective trial were recently published. The trial demonstrated that hypoglossal nerve stimulation led to significant improvements in objective and subjective measurements of the severity of OSA. This novel approach is the first to combine sleep surgery techniques with a titratable medical device for the treatment of OSA. This patient has been treated with surgery for his OSA. He is status post tonsillectomy and UPPP, and has failed to achieve adequate results with CPAP. Based on these findings, the requested implantation of a hypoglossal nerve stimulator is likely to be more beneficial for this patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in otolaryngology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:    An enrollee has requested intensity modulated radiation therapy with x-ray guidance for treatment of her medical condition.  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  This patient has locally advanced gallbladder cancer which is a clinically rare condition.  Intensity modulated radiation therapy with x-ray guidance has been utilized to treat several malignancies, including upper abdominal malignancies.  There are few published data pertaining to intensity modulated radiation therapy for biliary-pancreatic area, and there is a lack of randomized or large cohort trials supporting the requested services in this case.  Thus, the requested intensity modulated radiation therapy with x-ray guidance is not likely to be more effective than other modalities.  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 radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a targeted genomic sequence analysis test for evaluation of her non-small cell lung cancer.   Two physician reviewers found that a portion of the testing at issue was likely to be more effective for this patient than other available options. The treatment of non-small cell lung cancer is guided by not only the specifics of the histologic type, but also the presence or absence of certain key mutations. Among the mutations that have been validated to be important in decision making are epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutations. These two tests are available as individual tests and it is not necessary that these tests be done as part of a larger panel. Therefore, the genomic profiling for EGFR and ALK were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.   Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  Two reviewers are board certified 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. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the use of breast tomosynthesis compared to conventional mammogram due to improved cancer detection rate. 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. Based on the medical literature cited above, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result:  Two rteviewers 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 the Bruno valet seat for treatment of his Angelman syndrome and cerebral palsy.  The physician reviewer found that the request for a Bruno valet seat is not medically necessary as it does not meet the definition of durable medical equipment per the Centers for Medicare and Medicaid Services (CMS). This definition states that the equipment is appropriate for use in the home but may be transported to other locations to allow the patient to complete instrumental activities of daily living which are more complex tasks required for independent living. The requested item will not be used in the home and therefore is not medically necessary for this patient to complete instrumental activities of daily living. Final Result: The reviewer determined that the requested device 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested Genotropin growth hormone (GH) therapy for treatment of the enrollees short stature. The physician reviewer found that this patient has failure to thrive and constitutional delay in association with a chronic inflammatory condition. Although his testing revealed a peak GH response of less than 10 ng/mL to provocative testing, such testing has poor specificity for the diagnosis of GH deficiency in a patient with delayed puberty who is also underweight. In addition, a low IGF-1 level in a patient who is underweight is not specific for GH deficiency. There is also a lack of biochemical evidence that this patient has other pituitary deficiencies to raise concern about a broader diagnosis of hypopituitarism. The primary cause of this patients growth failure and delayed puberty is poor weight gain, which may be related to his chronic inflammatory condition. His pattern of continued fall-off in weight and low weight-to-height ratio is not consistent with a diagnosis of GH deficiency as the primary diagnosis. The fact that the patient has not responded well to GH treatment and recent height standard deviation score is lower than the pre-treatment height score suggests that other causes and treatments of his growth failure be considered, and continuation of Genotropin GH therapy 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 pediatric endocrinology 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 12 weeks for treatment of his hepatitis C virus (HCV).  Finding:  Three physician reviewers found that treatment with Harvoni is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. In this case, the patient has advanced fibrosis and therefore, it is medically necessary to treat him with HCV therapy with Harvoni to potentially eradicate HCV infection and prevent further progression of advanced fibrosis to cirrhosis and its complications. Based on the documentation submitted for review and national guidelines Harvoni for 12 weeks is medically for treatment of the patients medical condition. 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 gastroenterology and is actively practicing. Two 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the MyRisk genetic marker test for evaluation of his colon polyps.  Two physician reviewers found that while there is evidence that APC testing is indicated with familial adenomatous polyposis (FAP) and attenuated familial adenomatous polyposis (AFAP), there is a lack of support for hereditary breast and ovarian cancer (HBOC) genetic testing to justify testing for BRCA mutations. Based on the records, the patient also meets the criteria for testing for Lynch syndrome. Given these findings, the FAP, AFAP, and MUTYH-associated polyposis syndrome (MAP) testing portions of the MyRisk panel at issue were supported as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of the testing at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be partially overturned.  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 mental health inpatient treatment for treatment of his altered mental status and agitation. The physician reviewer found that dementia is a chronic and progressive disease complex that often demands treatment in specialized facilities in the later stages of the illness. Transient treatment in acute settings, as seen in this case, is also often necessary due to the myriad of biopsychosocial complexities associated with major neurocognitive disorders. In this case, the services at issue were medically necessary. The patient remained engaged in active treatment that was reasonably expected to improve his condition and prevent a more serious episode of illness. The patient remained on one-on-one nursing supervision and required staff assistance with activities of daily living. Further, he was in need of dermatologic consultation and physical therapy assessment, while his medication regimen was up-titrated. Thereafter, the inpatient team optimized the medication regimen, and provided appropriate clinical care and discharge planning services which ultimately resulted in a successful discharge to a suitable facility.  The Health Plan contends that the services provided were custodial in nature, and thus the level of care was not medically necessary. However, the services in dispute could not have been safely and effectively provided by non-health care professionals, and as such, did not qualify as custodial care. Both the clinical care and treatment setting were safe, appropriate and consistent with good medical practice. Thus, the services at issue were medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the services at issue were 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.