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

Nature of Statutory Criteria/Case Summary: An enrollee has requested hip surgery (surgical release of femoroacetabular impingement syndrome) for treatment of his medical condition.Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The services at issue are supported in the peer reviewed literature. The left hip surgery (surgical release of femoroacetabular impingement syndrome) likely avoided and/or delayed total joint replacement. Given the patients age, the alternative total hip arthroplasty would likely require revision arthroplasty. All told, the left hip surgery (surgical release of femoroacetabular impingement syndrome) was 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 service 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 orthopedic surgery 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 proton beam therapy for treatment of her medical condition. Findings:  The physician reviewer found that the standard approach to treat breast cancer with a partial technique is to use a three-dimensional conformal or intensity modulated technique. When using protons to treat breast cancer there are concerns because the dose delivered to the skin is the full prescription dose which is higher than the skin dose with photon techniques. In this case, the clinical documentation submitted has not described an adequate clinical reason which would preclude the use of a standard partial breast technique. Currently, there is insufficient clinical data to discern whether treatment with proton beam radiation offers a clinical benefit compared to conventional radiation therapy techniques in the treatment of all stages of breast cancer. The National Comprehensive Cancer Network guidelines also state the standard for treating breast cancer is with conventional photon techniques. Therefore, proton beam therapy is not medically necessary in the 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 radiation oncology 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 denervation of sacroiliac joint for treatment of his medical condition. Findings:  Two physician reviewers found that SI joint pain is a well-documented syndrome with symptoms including low back, buttock and thigh pain and sometimes sciatic-like radiating pain. Along with conservative measures like anti-inflammatories, heat, ice and some manipulation, SI joint injections have shown merit in regards to fluoroscopic guidance with local and steroid with inter-articular placement of the medication. In this case, the patient has had a number of interventions, with the provider looking for the source of this patients pain. Multiple therapies have been tried with little success. Treatment with SI joint injections has provided this patient with significant pain relief. Although the studies above are limited in terms of double-blinded studies, this patient continues to have pain even after a number of interventions. As such, the request for denervation of sacroiliac joint is 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 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an Otto Bock Genium X3 microprocessor-controlled knee for treatment of her medical condition.  Findings:  The physician reviewer found that the Otto Bock Genium X3 microprocessor-controlled knee is medically necessary for treatment of the patients medical condition. Researchers have concluded The Genium knee generally increases flexion in swing and stance, potentially decreasing the level of impairment for persons with transfemoral amputation. This study demonstrates functional differences between the C-Leg and Genium knees to help prosthetists determine if the Genium will provide functional benefits to individual patients. In addition, researchers compared the C-Leg and Genium microprocessor-controlled knees concluding that Results showed that use of the Genium facilitated a more natural gait biomechanics and load distribution throughout the affected and sound musculoskeletal structure. This was observed during quiet stance on a decline, walking on level ground, and walking up and down ramps and stairs.  In sum, the literature demonstrates that the C-Leg and Genium knees are not equivalent. Therefore, the request for Genium knee is medically necessary for the treatment of this high functional patients amputation.  Final Result: The reviewer determined that the requested device 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni 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 infection regardless of fibrosis stage.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Technivie and ribavirin 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.  The guidelines recommend that treatment-naive genotype 4 patients should be treated with Technivie and ribavirin for 12 weeks.  All told, the requested treatment with Technivie and ribavirin is medically necessary for the treatment of this patients hepatitis C infection.  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: An enrollee has requested Harvoni 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, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin 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 infection regardless of fibrosis stage.  All told, Harvoni 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for birth defects (fetal aneuploidy trisomy risk) for the evaluation of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Cell-free DNA testing is not currently recommended for low-risk patients.  High-risk criteria which support the services at issue include 35 years of age or older at the time of delivery, sonographic findings associated with fetal aneuploidy, history of previous pregnancy with fetal trisomy, parental balanced robertsonian translocation with increased risk of trisomy 21 or 13, and screen-positive result for aneuploidy on screening tests such as the first trimester combined test, integrated test, sequential test, or quadruple test.  In this case, the records do not document risk factors which would support the services at issue.  Other covered screening modalities were available to this patient.  In sum, the genetic testing for birth defects was not likely to have been superior over other available modalities for evaluating this patient. Final Result: Three 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 obstetrics and gynecology 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 residential treatment program services for treatment of his behavioral health condition.  Findings: The physician reviewer found that residential treatment program services are medically necessary for treatment of the patients medical condition. Based on the documentation provided, the patients mental illness causes significant impairment across multiple functional domains. The adequately dosed evidence-based pharmacotherapy, in conjunction with weekly psychotherapy facilitated by specialty provider, appears to be inadequate as the patient has been unable to generate any meaningful therapeutic progress or consolidate the foundation necessary for recovery. Further, the treatment team who knows this patient best has recommended a residential placement. In sum, the proposed treatment would reasonably be expected to improve the patients condition and prevent a more serious episode of illness.  Further, residential placement would be considered safe, appropriate and consistent with good practice. Considering the clinical presentation and perusal of the peer-reviewed literature, residential treatment program services are medically necessary for treatment of the patients behavioral health condition.  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 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 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 recommend that 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 is medically necessary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested AmniSure testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that AmniSure testing has been recommended as an adjunct to standard assessment of pooling, ferning and nitrazine testing of vaginal fluid if these tests are not conclusive. AmniSure is not recommended as a first-line test. A prospective study found placental alpha-microglobulin-1 in cervicovaginal secretions is superior to conventional clinical assessment in the diagnosis of rupture of membranes. However, studies have also found false-positive test result rates of 19-30% in patients with clinically intact membranes and symptoms of labor. Given that the patients ultrasound did not show decreased amniotic fluid volume and she did not undergo standard testing prior to AmniSure testing, the testing was not medically indicated or likely to be more beneficial for evaluation of the patients medical condition than standard testing.  Final Result: Three reviewers determined that the testing at issue was 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 obstetrics and gynecology 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 and ribavirin 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based ribavirin 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 2 regardless of fibrosis stage.  AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography (CT) scans and associated services on an emergent or urgent basis.  Findings: The physician reviewer found that the review of the submitted clinical documentation fails to demonstrate that a prudent layperson would have sought immediate medical attention on the date in question. The patient presented with slow emptying velocity of the left atrium. This condition in and of itself is not considered an emergent situation. Furthermore, the submitted documentation does not demonstrate the patient was experiencing acute or severe symptoms on the date of service in question such that a prudent layperson would believe he was experiencing a medical emergency. All told, the patients symptoms did not meet prudent layperson criteria for emergency care.Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with no signs or symptoms evident of a serious medical condition. The records do not document the patient had a stroke or thrombus in his left atrium. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in thoracic 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.