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 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 1a patients should be treated with Harvoni for 12 weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  The patient is ineligible for the alternative for genotype 1a, Viekira Pak with ribavirin, due to pre-existing medical conditions, which can be exacerbated by ribavirin.  For these reasons, 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 the UroLift procedure for treatment of his medical condition. Findings: Three physician reviewers found that the current medical evidence has not established the superior efficacy of the requested services.  Long-term studies and comparative studies with transurethral resection of the prostate have not been completed.  Current guidelines do not recommend UroLift in this clinical setting.  All told, the requested UroLift procedure is not likely to be superior over other treatment options.  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 physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for drug metabolism for evaluation of his medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient has mixed hyperlipidemia.  There is no indication for genetic testing for response to statin medications.  The testing will not add any clinically significant information to the care of this patient.  There are drugs for which genetic testing is appropriate.  However, first-line medications used in the treatment of lipid disorders are not in this category.  All told, genetic testing for drug metabolism was not likely to have been of greater benefit than other methods of 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 internal 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 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.  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, 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.  This patient is ineligible for the alternative regimens with ribavirin due to depression, which can be exacerbated by ribavirin.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment 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 was not a danger to himself or others.  He was medically and psychiatrically stable.  He was working in school and actively participating in his therapies.  He had greatly improved in his behavior and was developing insight.  There was no evidence to show that returning him to his home environment would be detrimental to his continuing treatment.  During the dates of service in dispute, he could have safely and effectively been treated at a lower level of care.  All told, residential treatment was not medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Euflexxa injections 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 medical literature does not support viscosupplementation in this clinical setting.  Jevsevar and colleagues performed a systematic review to determine the clinical significance of injectable hyaluronic acid.  Meta-analysis of only the double-blinded, shamcontrolled trials did not show clinically important differences of hyaluronic acid treatment over placebo.   All told, the requested Euflexxa injections 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 orthopedic 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a total hip arthroplasty for treatment of his medical condition.   Findings:  The physician reviewer found that the requested total right hip arthroplasty has been established as medically necessary in this clinical setting. The patient has had increasing mechanical symptoms, increasing pain and functional impairment following right hip resurfacing arthroplasty. The patient has a well-functioning total hip arthroplasty on the opposite side. He has not shown elevated chromium and cobalt metal ion levels, however, the mechanical symptoms alone and the increasing pain he is experiencing provides a reasonable and persuasive indication that conversion to total hip arthroplasty is appropriate. The history of total hip arthroplasty also supports the lack of likely long term efficacy for resurfacing procedures in general. The original early stages of arthroplasty at the hip included attempts to resurface rather than to replace. These attempts historically all failed. Based on the peer-reviewed literature and clinical documentation the requested total right hip arthroplasty is clinically indicated for the treatment of the patients medical 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 orthopedic 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 peripheral bone mineral density (BMD) testing and breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Breast tomosynthesis is U.S. Food and Drug Administration (FDA) approved as an adjuvant method of screening along with traditional mammography. In the screening setting, tomosynthesis helps to decrease recall rates by delineating true lesions from spurious lesions caused by overlapping structures seen on routine mammography. Several studies have compared screening by digital mammography alone with the combination of tomosynthesis and digital mammography and found that tomosynthesis increased cancer detection rates, decreased false positives, and decreased call back rates. Most major breast cancers utilized this method for screening patients, especially those with a prior history of breast cancer. Therefore, breast tomosynthesis for this patient was likely to be more beneficial then available standard therapy.  However, the peripheral bone mineral density testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Although BMD measurements at peripheral skeletal sites predict global fracture risk as well as BMD measurement at the hip or spine, the risk for fracture at a particular skeletal site is best estimated by measuring BMD at that skeletal site. The International Society for Clinical Densitometry (ISCD) recommends that the World Health Organization (WHO) criteria be applied to BMD measured by dual-energy x-ray absorptiometry (DXA), using the lowest T-score of the lumbar spine (preferably L1-L4), femoral neck, or total proximal femur. If BMD cannot be measured at either of these skeletal sites due to structural abnormalities, such as osteoarthritis or surgical artifact, then the distal 33 percent (one-third) radius should also be measured and considered for diagnostic classification. In this case, there is no indication in the clinical notes provided for review that the patient required peripheral measurement of her forearm.  Final Result: Two reviewers determined that a portion of the services 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 partially overturned.Credentials/Qualifications: All three physician reviewers are board certified in medical oncology 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 Lyrica for treatment of her medical condition. Findings:  The physician reviewer found that Lyrica is medically necessary for treatment of the patients medical condition. There is sufficient support in the evidence based literature supporting the requested services. Lyrica has been utilized off-label for many neuropathic pain syndromes. There is significant literature regarding the use of Lyrica in neuropathic pain other than diabetic neuropathy and post herpetic neuralgia. Lyrica is widely used by both headaches specialists and multiple sclerosis specialists to treat the conditions presented in this case. Finally, the medical records support an excellent response to the patients chronic migraine with the treatment of Lyrica. Given these facts, Lyrica is supported as medically necessary for treatment of this patients medical condition.  Final Result: The reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee is requesting prescriptions for Sovaldi and Daklinza for the treatment of his hepatitis C infection. Findings:  The physician reviewer found that according to 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 life expectancy of less than 12 months due to non-liver related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 12 weeks regardless of interferon eligibility. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al).  This regimen avoids interferon-related side effects. The guidelines cite data reporting that delay in treatment may result in decreased survival (Jezequel, et al). 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested inpatient psychiatric hospitalization 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.  During the dates of service in dispute, the patient was not a threat to herself or others.  She was not violent or aggressive, and she was medically stable.  Her medication management did not require inpatient monitoring.  She was cooperative and compliant.  She had improved and no longer required 24-hour monitoring.  There was no evidence that returning her to her home environment would lead to decompensation.  She still needed treatment for medication management and psychological and family treatment.  However, this treatment could be provided at a lower level of care such as intensive outpatient or outpatient.  All told, inpatient psychiatric hospitalization services, during the dates of service in dispute, were not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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: The parent of an enrollee has requested percutaneous sclerotherapy for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that the literature reviewed regarding sclerotherapy in this clinical setting consists of small case series and case reports. The medical literature supports surgical excision as the standard of care for orbital dermoid cysts. Based upon a review of the peer-reviewed literature as well as the recommendations of the treating physician, sclerotherapy is not indicated for this patient. The standard of care as indicated by the literature for treatment of dermoid cysts is surgical. While sclerotherapy may prove to be effective in time for the treatment of young children with this condition, the paucity of data on the success of this treatment in this patient population precludes a recommendation to supports its use as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  One reviewer is board certified in ophthalmology and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in critical care 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 Tysabri for treatment of her multiple sclerosis (MS). Findings:  The physician reviewer found that clinically it is reasonable to treat aggressive presentation of MS with more potent therapies, and this is now acknowledged in the Tysabri prescribing information. Tysabri is no longer indicated only for failure of other MS treatments. Also, per the prescribing information, Tysabri is indicated as monotherapy for the treatment of patients with relapsing forms of multiple sclerosis. While research indicates that Tysabri increases the risk of progressive multifocal leukoencephalopathy (PML) for some patients, for this patient the risk is offset by the benefit that Tysabri may bring in the treatment of her medical condition. For these reasons, initiating and continuing treatment with Tysabri was and is clinically appropriate and medically necessary for this patient.  Final Result: The reviewer determined that the medication at issue was and 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Forteo for treatment of her medical condition. Findings:  The physician reviewer found that current studies indicate that osteoporosis is an increasingly widespread condition, affecting 55% of Americans aged 50 and above. Of these, approximately 80% are women. Fractures are the most dangerous aspect of osteoporosis. They can lead to acute and chronic pain as well as increased mortality (Old and Calvert). Until recently, pharmacological options for the treatment of osteoporosis have been limited to antiresorptive agents, including the oral bisphosphonates. Newer treatment agents have become available over the past few years, including teriparatide (Forteo), which was initially approved for treatment of osteoporosis in 2002.  Forteo is a recombinant form of the biologically active component of parathyroid hormone which has been shown to increase bone mass and prevent fractures in osteoporotic bone (Drake et al).  In contrast to bisphosphonate medications, recent data also demonstrates that Forteo may aid in the healing of fractures and non-unions in osteoporotic patients (Babu et al).  Based on the submitted documentation and according to recent studies, Forteo is medically necessary in the treatment of this patients medical condition.  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 endocrinology and metabolism 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.