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 her hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that according to the most recent guidelines issued by the American Association foe the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment naive patients are recommended to be treated with Harvoni for 12 weeks.  These 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.  Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous.  Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, the requested Harvoni is medically necessary.  Final Result:  Three reviewers found that the requested medication is medically necessary for treatment of the patients medical condition.  Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty 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

A male enrollee requested an anus exam (high resolution anoscopy) for medical evaluation of his high grade squamous intraepithelial dysplasia and HIV.  Findings:  Two physician reviewers found that high resolution anoscopy is used in high risk populations for surveillance and has been endorsed by the National Comprehensive Cancer Network (NCCN) in this clinical setting.  Thus, the anal exam (high resolution anoscopy) was likely to have been more beneficial for evaluation of his medical condition than any available standard testing.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested an inpatient hospital stay for medical treatment of her nausea and vomiting with history of Roux-en-Y gastric bypass.   Findings:  The physician reviewer found that the records do not support that there were abnormalities, instability, or concerns to warrant hospitalization.  No imminent surgery was planned.  Accordingly, inpatient services were not medically necessary for treatment of the patients medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested chelation therapy with ethylenediaminetetraacetate acid (EDTA) for medical treatment of her medical condition.  Findings:  Two physician reviewers found that in this case, repeated assays of the patients blood manganese levels are not in the range of patients with genetically confirmed disease.  This casts doubt on whether the patient has the described syndrome. In addition, in cases where patients with elevated manganese levels have reportedly derived neurological benefit from chelation therapy, this occurred where levels were significantly elevated, and where neurological benefit from chelation was correlated with a reduction in manganese levels. In the absence of this information, the requested chelation therapy is not supported as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers have determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The Health Plans denial should be upheld.   Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing.  One reviewer is board certified in internal medicine with sub-specialty certification in hematology and is actively practicing.  One reviewer is board certified in oncology and hematology 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 knee arthroscopy for treatment of her right knee pain related to a medial meniscus tear.  The physician reviewer found that review of the submitted documentation fails to demonstrate the medical necessity of the requested procedure. According to the documentation submitted for review, there is a lack of documentation of adequate conservative measures tried such as physical therapy for knee pain. In this clinical setting, conservative measures are needed for the treatment of knee pain. In addition, there are no red flags documented for knee surgery such as locked knee motion, concern for fracture or tumor. All told, the request for knee arthroscopy is not supported as medically necessary.   Final Result: The reviewer determined that the requested procedure 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested continued/extended care at a rehabilitation center for treatment of her right femur pathological fracture.  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued/extended care at a rehabilitation center has not been established. According to the American Association of Physical Medicine and Rehabilitation (AAPMR) standards for determining appropriate of admission of rehabilitation, the patient needs to have significant functional deficits and medical and nursing needs that require close medical supervision with 24-hour availability of skilled rehabilitation nurses. In this case, the patient does not have acute medical issues interfering with rehabilitation. She does not have nursing or medical needs that require SNF or acute rehabilitation facility care. She will benefit from continued skilled physical and occupational therapy which she can pursue as an outpatient. In addition, the patient has been provided home therapies and adaptive equipment. Therefore, continued/extended care at a rehabilitation center is 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees major depressive disorder and post-traumatic stress disorder (PTSD).  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting. In general, community intervention settings offer optimization of treatment gains. However, due to multiple factors and unique considerations, determination of the appropriate level of care and length of stay for adolescent patients with multiple psychiatric conditions can be a challenging endeavor. Based on this patients longitudinal history, psychiatric comorbidity, symptom complex, family environment, characterological organization and psychosocial factors, a conservative residential stay is to be expected. She has chronic suicidality, depressive symptoms, anxiety and strained relations with father, in addition to poor insight and little investment in her treatment. In reviewing the clinical documentation, the services are reasonably expected to improve the patients condition and prevent a more serious episode of illness. The evaluating team and her treatment providers have recommended residential care. Considering the patients current status, recent behaviors and clinical history, she would likely decompensate in the absence of treatment at the residential level of care. The evidence-based services provided thus far have been for active treatment and have been delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting. The anticipated discharge date will allow the team to determine the best aftercare plan and facilitate a seamless transition to the next treatment setting. For these reasons, the residential treatment center services were and are supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the services at issue were and 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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested mental health intensive outpatient services for treatment of his obsessive compulsive disorder.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The records document a debilitating anxiety disorder that impairs multiple domains of functionality.  In accordance with modern psychiatric practice, the patient had first pursued treatment in the outpatient setting.  He failed that level of care and was referred to an intensive outpatient program.  Based on the documentation provided, this patient had neither integrated the sustained learned behaviors nor consolidated the treatment gains necessary to succeed in a less restrictive setting.  Subsequent psychiatric evaluation noted passive suicidal ideation along with an anxious and sad presentation in context of severe and disabling obsessive compulsive disorder.  In addition to the obsessive compulsive disorder, the patient was diagnosed with posttraumatic stress disorder and major depressive disorder.  The evidence-based services have been for active treatment and are being delivered in accordance with an individualized treatment plan aimed at successfully transitioning the patient to a less restrictive setting.  Based upon current practice guidelines and relevant peer-reviewed literature, mental health intensive outpatient services were and are medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were and 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 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:   The parent of an enrollee requested residential substance use services for treatment of his polysubstance dependence. The physician reviewer found that according to the documentation submitted for review, the patients substance abuse is not clear as there is no admitting psychiatric evaluation, no substance abuse history and no description of what the precipitating factors were leading up to his admission. It is also not clear what treatment he received for substance abuse as there was no documentation regarding the presence or absence of withdrawals, or what substances of abuse were the focus of this admission. There was no documentation provided of any substance abuse counseling, meetings attended or educational groups. There was mention of the patients ongoing desire to use. The documentation submitted for review included individual, group and family psychotherapy notes, which focused around the patients depressed mood, sense of low self-esteem, and triggers.  While in need of continuing care, the patient did not require substance use services at the residential level of care. The patients treatment could continue at a lower level of care. Therefore, residential substance use services were not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested medication is medically necessary to prevent further progression of fibrosis due to ongoing hepatitis C infection and prevent potential complications of advanced liver disease.  All told, Harvoni is medically indicated for the treatment of this patient.  Final Result:  Two reviewers determined that that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be 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 Olysio and Sovaldi for treatment of his hepatitis C.  Two physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  All told, the requested Olysio and Sovaldi are medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: 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 Sovaldi for treatment of her hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Treating patients with early stage disease may avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C.  All told, Sovaldi is medically indicated for the treatment of this patient.   Final Result: Two 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:  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a fecal transplant for treatment of his Clostridium difficile (C. difficile) infection. Three physician reviewers found that the requested fecal transplant is likely to be more effective for this patient than other available treatment options. Cumulative experience from case series and reports shows that fecal bacteriotherapy has been used to treat relapsing C. difficile infection. Several studies and meta-analyses have demonstrated efficacy of FMT in the treatment of C. difficile-associated diarrhea in patients with recurrent disease after initial antibiotic therapy. Limited observational data also suggests that treatment with FMT is associated with resolution of C. difficile-associated diarrhea in patients with severe disease. Based upon the multiple studies published in the peer-reviewed literature, FMT has now become the standard of care for the treatment of recurrent C. difficile infection and is likely to be more beneficial for treatment of the patients C. difficile than any available standard therapy. Final Result: Three 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology and are actively practicing.  All three reviewers are 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 ablation of the esophagus for treatment of his Barretts esophagus. The physician reviewer found that the superior effectiveness of the services at issue has not been established.  The published medical literature does not demonstrate that the requested procedure has been proven safe and effective in this clinical setting of Barretts esophagus with no dysplasia.  At this time, there is a lack of long-term data on the safety and benefit of radiofrequency ablation (RFA) for non-dysplastic Barretts esophagus.  Thus, RFA is not currently recommended for patients without evidence of dysplasia on biopsies.  In sum, ablation of the esophagus was not likely to have been superior over other treatment alternatives.  Final Result: The reviewer determined that the services at issue were 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: 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.