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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of 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, 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 regardless of fibrosis stage.  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: 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 (HCV).  Findings:  The physician reviewer found that as per the combined American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD/IDSA) guidelines, treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies due to comorbid conditions. This recommendation was given a rating of Class I, Level A. This recommendation was formulated based on the recognized benefits associated with successful HCV treatment. Clinicians should treat HCV infected patients with antiviral therapy preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of sustained viral response. In sum, the requested authorization and coverage of Harvoni is medically necessary in treatment of the patients hepatitis C virus. Final Result: The reviewer determined 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 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 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, 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 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a positron emission tomography/computed tomography (PET/CT) diagnostic screening for colon cancer. Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The patient had no clinical signs of tumor recurrence and the previous PET/CT was negative with absence of any clinical or a biochemical finding to indicate possible tumor recurrence. The PET/CT scan at issue was not likely to have been of benefit.  The National Comprehensive Cancer Network guidelines do not recommend PET/CT as routine surveillance if there is no clinical sign of tumor recurrence/metastasis.  All told, the PET/CT scan at issue was not likely to have been superior over other methods of evaluating this patient.Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are an 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 American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages this new technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only. In sum, 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested removal of gastric band and revision of gastric sleeve for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient underwent the laparoscopic adjustable gastric band  without documented complication or intolerance.  Given the lack of any documented anatomic complication, intolerance, and lack of any updated multidisciplinary evaluation to determine whether she would be a reasonable candidate for revision, the medical necessity of the requested procedure is not established.  All told, the requested removal of gastric band and revision of gastric sleeve are not medically indicated for the treatment of this patient.   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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 due to the advantages tomosynthesis brings to radiologists interpreting mammograms the American College of Radiology (ACR) has urged the technique be removed from the investigational category. Tomosynthesis often allows radiologists to subtract out dense glandular elements from mass/architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. In this case, the tomosynthesis portion identified a second mass otherwise not seen and directed an ultrasound to this area for further evaluation. Thus, the addition of tomosynthesis was of more benefit to the patient than had the exam been done with two-dimensional imaging alone. Final Result: Two 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a vertical sleeve gastrectomy for treatment of her morbid obesity.  Findings:  The physician reviewer found that this patient has history of the laparoscopic adjustable gastric band placed and then removed  secondary to technical complications of the device. The patient had been very successful with the Lap-Band and since its removal has continued to regain weight. Unlike other bariatric procedures, the Lap-Band is a device that once removed no longer provides any ongoing weight loss tool. Patients who have technical or intolerance complications necessitating removal of the device should not be considered as primary bariatric candidates but as unique clinical circumstances warranting evaluation outside of standard BMI thresholds. Medical literature supports repeat bariatric surgery to the laparoscopic vertical sleeve gastrectomy, however, current dietary evaluation is recommended to ensure that patients are able to comply with the necessary dietary requirements and nutritional supplementation of micronutrients. In this case, no dietary evaluation has been documented; this is recommended as part of an updated multidisciplinary evaluation. Therefore, the medical necessity of laparoscopic vertical sleeve gastrectomy has not been established at this time. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in surgery with a fellowship in minimally invasive bariatric surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 current medical evidence supports breast tomosynthesis in this patients case.  The tomographic qualities of the exam has enabled radiologists to separate dense glandular elements from underlying architectural distortion/mass, resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the patients two-dimensional imaging was likely of more benefit to the patient than had the examination been done with two-dimensional imaging alone. Final Result: Two 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 gene testing for drug metabolism for treatment of her medical condition. Findings:  Three physician reviewers found that the documentation submitted for review fails to support the gene testing for drug metabolism. There is a lack of clinical justification demonstrating the indication for the testing at issue.  Moreover, it is not clear how the data would impact clinical decision making, and how it would affect the patients health outcome. Pharmacogenomic testing while potentially useful in making therapeutic decisions has not been widely adopted by the medical community (Stanek et al.) 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 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: 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 there is insufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improve breast cancer detection and have the potential to reduce false positive recalls. However, in this particular patient, the submitted documentation does not indicate that there were problems to be resolved. Although the patient has a family history of breast cancer, medical literature has not shown significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially in view of the extra radiation dose. Based upon the information set forth above, along with peer-reviewed literature, the services at issue were not likely to be more beneficial for evaluation of the patients breast examination 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: One reviewer is board certified in internal medicine with sub-certification in diagnostic radiology and is actively practicing. Two reviewers are board certified in radiology with sub-certification 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:  Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The medical literature supports the services at issue in this clinical setting. The American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category due to the advantages this tomographic technique brings to radiologists interpreting mammograms. The advantage is due to the ability to often separate dense glandular elements from underlying mass/architectural distortion thereby decreasing callbacks and increasing detection of small cancers. For this reason the addition of tomosynthesis to the two-dimensional (2D) imaging protocol was likely of more benefit to the patient than had the exam been done with 2D imaging alone. Final Result: Two 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested inpatient hospitalization for eating disorder treatment for the 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 was not a danger to herself or others.  She was actively participating in her treatment, attending therapy sessions, and was compliant with her meal plan.  She was medically stable.  She was tolerating her medications.  Although she continued to endorse anxiety and negative associations around mealtime, she had improved and it did not appear that stepping down to a lower level of care would cause her to decompensate.  Per the medical records, she no longer required inpatient level of care.  All told, inpatient hospitalization for eating disorder treatment was not and is not medically necessary for the treatment of this patient.Final Result: The reviewers determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) but if PHP is not medically necessary, the enrollee requests intensive outpatient program (IOP) for treatment of her behavioral health condition. Findings: The physician reviewer found that Ketamine is an N-methyl-D-aspartate (NMDA) antagonizing dissociative drug commonly used as an anesthetic. There are no Food and Drug (FDA) approved medications to treat addiction to ketamine or other dissociative drugs. Per accepted medical guidelines and scientific literature, the treatments of choice in this setting are chemical dependency services and behavior therapy. This patient has a severe substance use disorder with comorbid anxiety and depression. Her addiction dominates her functionality while her co-occurring psychiatric issues hinder her recovery. The records indicate that she has significant interpersonal, occupational, financial, and social impairment. As such, her illness burden demands comprehensive specialty care. A recent clinical evaluation recommended intensive outpatient programming. There is no documentation suggesting an improvement in the patients condition that would support treatment in a less restrictive setting.  Conversely, there is no evidence indicating that services provided by an intensive outpatient program would be inadequate, thus necessitating a higher level of care. Thus, although the requested PHP is not medically necessary, IOP is reasonably expected to improve the patients condition and prevent a more serious episode of illness and therefore is clinically indicated.  Medical literature supports IOP services in this case and these services are recognized as safe, appropriate and consistent with good medical practice.  Thus, the requested IOP services are medically necessary for treatment of the patients behavioral health condition.  Final Result: The reviewer determined that the requested partial hospitalization program (PHP) services are not medically necessary, the requested intensive outpatient program (IOP) services are medically necessary. Therefore, the Health Plans denial should be partially 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.