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

Nature of Statutory Criteria/Case Summary: An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition. Findings:  Three physician reviewers found that breast tomosynthesis has gained worldwide popularity among radiologists due to an associated decrease in callbacks and increase in detection of small cancers.  In cases where the breast tissue is extremely dense or heterogeneously dense, the tomographic features of tomosynthesis allow the radiologist to sort out dense glandular tissue from architectural distortion and perhaps underlying mass.  All told, breast tomosynthesis was likely to have been of greater benefit to the patient than digital mammography without tomosynthesis.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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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.
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.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and Daklinza for 12 weeks for treatment of his hepatitis C virus (HCV).  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) Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV. Moreover, treatment delays may decrease the benefit of SVR. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. In addition, per AASLD/IDSA guidelines, daily daclatasvir and sofosbuvir for 12 weeks is recommended for treatment-naive patients with HCV genotype 3 infection. The ALLY-3 study concluded that a 12-week regimen of daclatasvir plus sofosbuvir achieved SVR at 12 weeks in 96% of patients with genotype 3 infection without cirrhosis and was well tolerated. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Sovaldi and Daklinza for 12 weeks is medically necessary in this case. 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 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 continuous treatment of Harvoni for 24 weeks for treatment of her hepatitis C virus (HCV). Findings:  The physician reviewer found that Harvoni for 24 weeks is medically necessary for treatment of the patients medical condition. In the ION-2 study, 440 HCV patients underwent randomization and were treated, 20% had cirrhosis and 79% had HCV genotype 1a infection. The rates of sustained virologic response were high in all treatment groups. There was a 99% (95% confidence interval (CI), (95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and 99% (95% CI, 95 to 100) in the group that received 24 weeks of ledipasvir-sofosbuvir and ribavirin. The results of an abstract were presented at the American Association for the Study of Liver Diseases Liver Meeting. In this double-blind study, Bourliere and colleagues randomized 155 patients previously unable to achieve a sustained virologic response after sequential treatment with a peginterferon and ribavirin regimen followed by a protease-inhibitor (PI), peginterferon  and ribavirin regimen. The patients underwent treatment with ledipasvir/sofosbuvir and ribavirin placebo for 24 weeks or matching placebo for 12 weeks, followed by ledipasvir/sofosbuvir and ribavirin for 12 weeks. Patients were stratified by HCV subtype and their responses to their most recent therapy. Of the 77 patients treated with ledipasvir/sofosbuvir and ribavirin for 12 weeks, 4% experienced relapse; compared with 3% of the 77 patients treated with ledipasvir/sofosbuvir for 24 weeks, for a 3% total incidence of relapse. Based on the peer-reviewed literature, Harvoni for 24 weeks is medically necessary in this clinical setting. Final Result: The reviewer determined that the requested medication duration 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 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 continued partial hospitalization program (PHP) services for treatment of his behavioral health condition. Findings: The physician reviewer found that a comprehensive aftercare plan has been developed consisting of intensive outpatient programming, individual therapy, psychiatric services, couples counseling and continued community programming. The patients willingness and ability to address issues from his past signifies meaningful therapeutic progress commonly seen in sustained sobriety. The further pursuit of reconciling intrapsychic conflicts via insight-oriented or psychodynamic therapy, or on-going relapse prevention efforts for that matter, do not require the partial hospital level of care. Based on the data provided, the comprehensive treatment plan developed by the Health Plan is safe, appropriate and consistent with good medical practice. Thus, an extension of services at the PHP level of care is not medically necessary. 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 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 magnetic resonance imaging brain, with and without contrast, magnetic resonance spectroscopy and positron emission tomography body and skull base for evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the requested services. From the records, it would appear that a metastatic cancer is highly unlikely and therefore the requested positron emission tomography body and skull base scan has limited utility.  If sarcoid is suspected, there are other methods to determine that likelihood, including chest computed tomography scan, gallium scan of the lungs, and lacrimal gland biopsy.  Magnetic resonance spectroscopy is widely used to determine grade of malignancy, and to tell the difference between a malignant tumor and a benign inflammatory lesion.  In this case, where there is a question as to a glioma or an inflammatory magnetic resonance spectroscopy could be beneficial and assist the providers in treatment planning.  Magnetic resonance imaging of the brain is also medically indicated for the evaluation of this patient.  All told, magnetic resonance imaging brain, with and without contrast and magnetic resonance spectroscopy are medically indicated for the evaluation of this patient.  However, the records fail to demonstrate the medical necessity of positron emission tomography body and skull base. Final Result: The reviewer determined that a portion of the requested services is medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested cervical spine magnetic resonance imaging (MRI) neurogram and an upper extremity MRI neurogram for evaluation of his left brachial plexus injury.  Findings:  Two physician reviewers found that the request for cervical spine MRI neurogram and an upper extremity MRI neurogram is likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Magnetic resonance (MR) imaging is an excellent tool for the evaluation of peripheral nerves in children not only because of its excellent soft tissue contrast resolution but also because it is noninvasive and does not use ionizing radiation. In non-conclusive cases, MR neurography can be complementary to physical examination and electromyography in identifying a specific affected nerve and the site of the lesion. Moreover, researchers state MR neurography is an extremely useful modality to image the traumatized brachial plexus. It influences both surgical planning and outcome/prognosis. Thus, there is support in the medical literature for the use of MR neurography for the evaluation of peripheral nerve injury and consideration for surgery. All told, the requested diagnostic procedures are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the requested diagnostic procedures are 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 the UroLift prostatic urethral lift procedure for treatment of his benign prostatic hyperplasia.  Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of medical literature supporting the requested services in this clinical setting. UroLift is still undergoing data collection for its role in different clinical situations and has not been shown to exceed the efficacy of standard treatment of benign prostatic hyperplasia (BPH) or decrease the long-term complications or recurrence rate. Therefore, given the lack of support in the peer-reviewed literature the UroLift prostatic urethral lift procedure has not been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the requested 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 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 Ampyra for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This medication was tested with a timed walk, as it is a relatively easy end-point to measure.  The Health Plan is using a 20% improvement from baseline as the requirement for coverage for Ampyra and does not take into account multiple sclerosis relapse or natural progression of disease that may cause worsening of gait.  This patient appears to have had significant worsening in her overall disability including walking ability, and a slowing of 25-foot timed walk would not necessarily indicate a failure of the drug, but a worsening in underlying multiple sclerosis.  If this patient initially responded well to Ampyra, it is likely the drug will continue to have a positive effect.  All told, the requested Ampyra 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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis performed for evaluation of her breast pain. Findings:  Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates when tomosynthesis has been added to the usual screening mammography protocol, the addition of the technique has gained worldwide support among providers due to an associated significant decrease in callbacks and increased detection of small cancers. This advantage is due to the tomographic quality of digital tomosynthesis and the advantage of having the ability to eliminate the confusion and artifact of glandular breast tissue either mimicking or obscuring a mass. Thus, the addition of the technique is considered more beneficial for the patient than mammography alone. Consistent with these findings, the breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 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 a referral for acupuncture services for treatment of her medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this patients case.  In regards to the chronic lower back complaints, acupuncture may be recommended as an option for chronic low back pain using a short course of treatment in conjunction with other interventions.  Acupuncture has been found to be more effective than no treatment for short-term pain relief in chronic low back pain.  Regarding the use of acupuncture for the knee osteoarthritis, recent clinical trials concluded that acupuncture treatment of knee pain produces significant improvement in physical capability and psychological functioning.  All told, the requested referral for acupuncture services is medically indicated for the treatment of 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 oriental 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested food allergy testing (IgG food sensitivity testing) for evaluation of her medical condition. Findings:  Two physician reviewers found that patients with suspected food allergies are commonly seen in clinical practice.  The most common foods that produce allergic symptoms are milk, eggs, seafood, peanuts, and tree nuts.  In order to distinguish true food allergies from food intolerance, food dislikes, and other conditions that mimic food allergy, testing has over the years taken several directions.  However, in this patients case, the IgG food antibody assessment is unsupported by her available records or peer-reviewed literature.  The standard of care in this case would have been to systematically pursue diet food eliminations and assess response, without the preliminary IgG testing under dispute.  All told, food allergy testing was not likely to have been of greater benefit than other methods of evaluating this patient.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: Reviewers 1, 2, and 3 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 breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the breast tomosynthesis performed on was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Although there is a lack of long-term studies demonstrating an increased survival rate when tomosynthesis has been added to the usual screening mammogram films, the addition of the technique has gained worldwide support among providers due to the tomographic properties of the technique which in turn have led to a decrease in callbacks and increase in detection of small cancers. This advantage is due to the ability to largely eliminate the problem of overlying glandular elements which can be confusing to radiologists in the attempt to find subtle areas of mass density or architectural distortion which may in turn be associated with early cancer.  Therefore, in this clinical setting the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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.