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 12 weeks 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.  Per the guidelines, treatment-naive genotype 1 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.  For these reasons, the requested treatment with Harvoni for 12 weeks 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:  Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to screening mammography has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  The advantage is the ability to sort out dense glandular tissue from underlying architectural distortion and mass due to the tomographic qualities of the new technique.  Breast tomosynthesis is beneficial for evaluating women with very dense or heterogeneously dense breast tissue.  Thus, breast tomosynthesis performed was likely to have been of greater benefit to the patient than digital two-dimensional mammography 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: The three reviewers are board certified in diagnostic radiology and is actively practicing. The 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 transcatheter closure of patent foramen ovale for treatment of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support for transcatheter closure of patent foramen ovale in this clinical setting.   Per the medical literature, the requested services are beneficial in the prevention of recurrent neurologic events.  The records document that this patient is intolerant to standard medical therapy.  In this patients case, the requested transcatheter closure of patent foramen ovale is likely to be more effective than other treatment alternatives.  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 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 magnetic resonance imaging (MRI) of the lumbar spine for evaluation of his chronic low back pain.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. According to Chou and colleagues, Clinicians should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). In general, plain x-rays serve to evaluate for significant structural abnormalities such as fractures, misalignments, congenital anomalies, etc. Patients can have significant disc herniation with normal plain x-rays; and conversely, patients with degenerative change in the lumbar spine may not have significant disc encroachment. However, the optimal testing to establish whether or not the patient has a disc herniation or spinal stenosis is to obtain cross-sectional imaging by either computed tomography (CT) or MRI, and MRI is preferable. In this case, the patient reports chronic low back pain. In this clinical setting an MRI is clinically indicated, and even if full invasive back surgery is not performed, a facet or epidural injection would provide some relief and it is only after an MRI that one could direct that type of limited therapy.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 Zetonna at a frequency of two sprays per nostril per day for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the medication at issue. The Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines recommend intranasal corticosteroids as first-line for allergic rhinitis, but do not recommend increased dosing beyond the U.S. Food and Drug Administration (FDA) approved dosage.  According to the manufacturers highlights of prescribing information, the maximum adult dosing of Zetonna is one spray each nostril daily. At this time, there is a lack of support in national guidelines or large randomized controlled trials recommending increased dosing of Zetonna beyond FDA approved dosing. As such, the request for Zetonna two sprays per nostril each day is not medically necessary.Final Result: The reviewer determined that the medication at issue was not and 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 allergy and immunology 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 percutaneous tibial nerve stimulation (PTNS) for treatment of her medical condition. Findings:  Two physician reviewers found that PTNS was not likely to be more effective for this patient than other available options. According to the American Urological Association (AUA) guidelines for the treatment of overactive bladder, PTNS is considered an acceptable third-line treatment option when first-line and second-line options have been tried and failed. In this case, there is a lack of documentation demonstrating that first-line and second-line treatments have been tried and failed. Therefore, the services at issue were not likely to be more beneficial than standard medical therapy in this clinical setting.Final Result: Two 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: The three reviewers are board certified in urology 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 and ribavirin for 12 weeks for treatment of his 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 state that cirrhotic patients are high priority for treatment.  Per the guidelines, cirrhotic treatment-experienced genotype 1 patients should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials.  All told, Harvoni and ribavirin for 12 weeks are medically indicated for the treatment of this patient.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:  The parent of an enrollee has requested shoe inserts for treatment of the enrollees flat foot.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested services. In this case, the patient complains of painful feet and the physical exam demonstrates overpronation with a pes planus foot structure. Based on the documentation submitted for review, the patient has poorly functioning biomechanics. Orthotics have been a long-standing, standard of care treatment for painful pes planus with overpronation. For this reason, the recommended shoe inserts are medically necessary for this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in podiatry 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 bortezomib injections for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the Health Plan denied coverage stating that bortezomib was approved for multiple myeloma and mantle cell lymphoma.  Primary amyloidosis due to immunoglobulin light chains and multiple myeloma are both plasma cell neoplasms.  Both diseases are the result of cancerous plasma cells that are secreting paraproteins.  In primary amyloidosis, the plasma cells involving the bone marrow are fewer in number than in multiple myeloma and the light chains have the protein characteristic of forming amyloid in tissues.  Both diseases are difficult to treat.  There is sufficient support for the requested medication in this clinical setting.  Bortezomib injections are the standard of care and are medically indicated for the treatment of this patient.  Final Result:  The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his 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.  Per the guidelines, patients with HIV are prioritized for treatment due to risk for complications.  The guidelines recommend the same hepatitis C treatment as patients without HIV, but drug-drug interactions should be taken into account.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials. For these reasons, the requested treatment with Harvoni for 12 weeks 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 Chantix for the treatment of his medical condition.  Findings: The physican reviewer found that per the medical evidence, smokers should be managed with a combination of behavioral support and pharmacologic therapy.  First-line agents for tobacco cessation include combination nicotine replacement therapy (transdermal nicotine patch combined with nicotine gum, lozenge, inhaler, and/or nasal spray), Chantix, and bupropion.  However, the use of Chantix in patients with a current unstable psychiatric status or a history of suicidal ideation is avoided.  Thus, combination nicotine replacement therapy is appropriate for patients for whom the safety of Chantix is a concern.  In patients with bipolar disorder, nicotine replacement therapy is a good first-line treatment.  The documentation submitted does not provide any history or details about his current psychiatric stability or any plan for monitoring for any behavioral changes and psychiatric symptoms while being treated with Chantix.  In this clinical setting, nicotine replacement therapy would be preferred over treatment with Chantix.  The documentation does not show he has failed treatment with nicotine replacement.  All told, Chantix is not medically indicated for the treatment of this patient.  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 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 Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) nationally recognized treatment guidelines there are several options with similar efficacy recommended for treatment-naive patients with HCV genotype 1b infection. Per AASLD/IDSA guidelines Harvoni has identical rating and equivalent efficacy as Viekira Pak. Per AASLD/IDSA, daily fixed-dose combination of ledipasvir/sofosbuvir (Harvoni) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection as a Class I, Level A rating. In addition, per guidelines daily fixed-dose combination of paritaprevir/ritonavir/ombitasvir (plus twice-daily dosed dasabuvir) for 12 weeks is recommended for treatment-naive patients with HCV genotype 1b infection as a Class I, Level A rating. The addition of weight-based ribavirin is recommended in patients with cirrhosis. However, this patient does not have cirrhosis, and therefore is a candidate for Viekira Pak without ribavirin. This regimen is highly recommended by AASLD/IDSA guidelines, and has been approved for the patients use in treatment of her HCV. As such, the request for Harvoni for 12 weeks is not medically necessary given the Health Plans approval of Viekira Pak for treatment of the patients HCV which has identical rating and equivalent efficacy per AASLD/IDSA guidelines.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 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: The parent of an enrollee has requested intensive outpatient program services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient continued to demonstrate active eating disorder behavior.  There was little supervision of her behavior outside of the program by her family.  Although the patient made some progress in identifying triggers of boredom and loneliness, the treatment plan was not changed to accommodate for her lack of progress.  Laboratory testing was only marginally out of range and her vital signs were stable.  Continuing treatment at this level of care was not expected to yield further improvement.  All told, intensive outpatient program services were not and are not medically indicated for the treatment of this patient.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Glassia for treatment of her medical condition. Findings: Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested medication.  The selection of appropriate patients in this scenario is critical, including a high-risk phenotype or a specific plasma alpha-1 antitrypsin level in a non-smoker or ex-smoker.  Since this patient is neither, she does not meet the criteria.  In this clinical setting, standard bronchodilator therapy and oxygen if indicated are appropriate.  Therefore, Glassia is not likely to be of greater benefit than other treatment options. Final Result: Three reviewers determined that the requested medication is 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 pulmonary disease and are actively practicing. The 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.