Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested a magnetic resonance imaging (MRI) or computed tomography (CT) scan of the upper back, lower back, neck, shoulders, and hips and Lyrica for evaluation and treatment of her medical condition.  Findings:  The physician reviewer found that Lyrica is not a medically necessary treatment for the patients chronic pain.  The documentation does not demonstrate that the patient has failed other anticonvulsant medications in the same class.  Gilron reviewed evidence-based literature supporting the use of gabapentin and pregabalin (Lyrica) for chronic neuropathic and early post-surgical pain.  The review concluded that these medications are efficacious treatments for neuropathic and post-surgical pain. Given the patient does not appear to be exhibiting neuropathic or radicular pain, the requested medication Lyrica is not medically necessary.  In regards to the MRI or CT scan, the patient did not have a neurological, sensory or motor deficit warranting these studies. The patients physical examination was significant for trigger points in the mid thoracic area.  Lumbar/thoracic/cervical MRI is indicated for physical examination findings consistent with nerve root impingement.  There is a lack of support for the requested imaging in this clinical setting.  The patients medical records do not demonstrate the medical necessity of the requested MRI or CT scan of the upper back, lower back, neck, shoulders, and hips. In sum, the requested services and medication are not medically indicated for the evaluation and treatment of this patient.  Final Result: The reviewer determined that the requested services and medication 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 with sub-specialty certification in 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:  The parent of an enrollee has requested Citrulline for the treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the requested medication has been established as medically necessary for treatment of the patients medical condition. Ornithine transcarbamylase (OTC) deficiency disorder can have serious effects if not treated.  Patients with OTC deficiency benefit from treatment with Citrulline. Citrulline is indicated to maintain a normal rate of protein synthesis. Without Citrulline the patient would be at risk of having high ammonia levels with severe consequences. Therefore, Citrulline has been established as medically necessary for treatment of the patients OTC deficiency. 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 pediatrics and pediatric 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 Estrogel for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  This patient has severe menopausal symptoms.  She indicates that she had adverse effects from oral estrogen and when she tried the estradiol patch.  The current medical evidence supports the requested medication in this clinical setting.  The treatment with transdermal estrogen gel is an appropriate option for this patient, and potentially safer than oral therapy.  The Health Plan requires that the patient try and fail an oral option and an estrogen patch prior to approval of Estrogel.  It appears that she meets this criteria.  In addition, she has used the Estrogel with good results.  In sum, Estrogel gel 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 obstetrics and gynecology 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 virus genotype 1a.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The patient is ineligible for the alternative, Viekira Pak with ribavirin, due to pre-existing medical conditions, which can be induced or exacerbated by ribavirin as shown in a placebo-controlled trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). 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 Kerydin for treatment of his medical condition.    Findings:  The physician reviewer found that the patient is requesting Kerydin therapy for treatment of onychomycosis of the toenails. The nail dystrophy present is due to an infection with a dermatophyte or mold, but culture results are not included. There is no documentation of an intolerance or contraindication to use of oral terbinafine, including abnormal liver function tests. The patient has documented that immune system dysfunction makes treatment with oral terbinafine contraindicated. However, treatment with terbinafine has not been proven to be a contraindication for patients with immune system dysfunction. Thus, the requested treatment with Kerydin is not medically necessary. In addition, treatment with Kerydin is not expected to provide a more than minimal improvement in the appearance of the nails. Onychomycosis is a common condition, which can be difficult to eradicate as recurrences are frequent. Treatment with oral terbinafine usually lasts four months and has a noted success rate, albeit with frequent recurrences. Avulsion of the nail plate can also be performed and allow better access for treatment of the nail bed with a topical antifungal. Treatment with Kerydin is expected to take 48 months of therapy and has low efficacy. Given these findings, the requested Kerydin is not reconstructive in nature for treatment of this patients onychomycosis.  Final Result: The reviewer determined that the requested medication is not reconstructive in nature and 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 dermatology 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

Credentials/Qualifications: An enrollee has requested radiofrequency neurolysis for treatment of her medical condition.  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.  Nature of Statutory Criteria/Case Summary: In the documentation available for review, there is no documentation of a diagnostic block prior to radiofrequency neurolysis.  In addition, the medical literature suggests that radiofrequency ablation only be performed after a diagnostic block with local anesthetic alone and a pain diary with notations of medication usage (Ferrante, et al; Cohen, et al). In the absence of this information, the requested radiofrequency neurolysis was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers 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: 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX anti-reflux procedure for treatment of her medical condition. Findings:  Two physician reviewers found that the LINX anti-reflux management system is not likely to be more effective for this patient than other available treatment options. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. The evidence review by Sheu and Rattner concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined. The available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment such as surgical fundoplication (Sheu, et al). Based on current literature, LINX is not likely to be more beneficial for treatment 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 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cardiac rehabilitation for treatment of her medical condition.  Findings:  The physician reviewer found that in this patients case, the submitted medical records do not demonstrate she presents with a condition that is likely to benefit from cardiac rehabilitation services. The effectiveness of post-operative cardiac rehabilitation services for patients who have undergone heart tumor resection has not been established. For these reasons, the requested cardiac rehabilitation 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 internal medicine with sub-specialty certification in cardiovascular disease 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 in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy. Final Result: The 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: 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 there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers, especially in women with dense breast tissue.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone. Final Result: Three 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: Experimental/Investigational
Decision: Upheld 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 one of the primary arguments supporting the use of tomosynthesis is that it reduces the frequency of callbacks for further evaluation of a suspected breast lesion. However, on occasion, it is necessary to obtain further images, and it is not unusual to perform additional imaging as well as a sonogram as in this clinical setting. In this case, the initial screening mammogram included tomosynthesis. While an initial tomosynthesis was indicated and successful in detecting an otherwise occult mass, a second tomosynthesis within a short period of time was not likely to yield additional data. Therefore, the second breast tomosynthesis was 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 services at issue were 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 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, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi for treatment of his medical condition.  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), 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 2 patients should be treated with Sovaldi and ribavirin. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, treatment with Sovaldi is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Tecfidera for treatment of her multiple sclerosis. Findings: Three physician reviewers found that in this case, this patient had previously been treated with Tecfidera for an extended period of time with no relapses or evidence of disease activity, and no reported adverse events. When the patient was switched to a therapy that required the use of injections, she was not compliant because of her fear of needles and therefore, therapies requiring the use of needles have not been proven to be effective for the patient. Tecfidera is a U.S. Food and Drug Administration (FDA) approved medication for relapsing forms of MS. Given the patients previous successful use of Tecfidera with good disease control and manageable side effects, the requested medication for treatment of this patients MS is likely to be more beneficial than the available formulary or any standard alternatives.  Final Result: Three reviewers determined that the requested medication 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: All three physician reviewers are board certified in 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.