Persius/hicric huggingface dataset:
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 hospital services for treatment of the enrollees behavioral health conditions.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient could have been managed at a lower level of care; her only issue was anger at not being discharged.  This anger led to a seclusion and restraint.  The patient reported that she was not suicidal.  Given her diagnosis of autism spectrum disorder, it is reasonable that she often misunderstands social cues and interactions.  This type of social skills deficit is better addressed in an ongoing social skills group.  The current medical evidence does not support inpatient level of care in this clinical setting.  All told, psychiatric hospital services were not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that 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 with sub-specialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The current medical evidence supports breast tomosynthesis in this clinical setting.  The addition of breast tomosynthesis to digital mammography has been associated with an increase in detection of small cancers.  Thus, the technique has proven to be of greater value when added to screening digital mammographic views than screening mammography alone.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result:  Two reviewers determined that 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1a. Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Therefore, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus. Final Result: two 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: All three reviewers 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: 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.   Two physician reviewers found that the medical evidence supports the requested medication in this clinical setting.  The current guidelines support treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  There is sufficient support for Harvoni for the treatment of this patient based on national guidelines.  All told, the requested Harvoni is medically indicated for the treatment of this patient.  Final Result:  Two 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: All three reviewers 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested percutaneous tibial nerve stimulation (PTNS) for treatment of her urge urinary incontinence.   The physician reviewer found that the requested services are not likely to be more effective for this patient than other available options. In this case, the patients symptoms of mixed stress and urgency incontinence have not been shown in the medical literature to respond to PTNS therapy, unless overactive bladder (OAB) is defined and isolated from stress incontinence. At this time, PTNS is not the standard of care in the case of complex urinary incontinence. For the reasons provided, PTNS is not likely to be more beneficial than standard medical therapy in this clinical setting.  Final Result: The reviewer 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: The reviewer is board certified in urology 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 the services of an assistant surgeon during a knee arthroscopy for treatment of the enrollees right knee arthroscopy. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for services of an assistant surgeon during a knee arthroscopy has not been established. In this case, the patient was noted to have undergone a right knee arthroscopic synovectomy, resection of the medial synovial plica, pigmented villonodular synovitis, and complete meniscectomy. However, there is a lack of documentation supporting the medical necessity for an assistant surgeon over a surgical technician or a trained surgical registered nurse to assist with the procedure. In sum, there is a lack of rationale provided to support the medical necessity for an assistant surgeon over another health professional to act as a surgical assistant. For the reasons provided, services of an assistant surgeon during a knee arthroscopy were not medically necessary for treatment of the patients medical condition. 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 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 Xifaxan  for treatment of her irritable bowel syndrome with diarrhea. The physician reviewer found that the current medical supports the requested medication for the treatment of this patient.  Xifaxan has been demonstrated to be effective for treatment of symptoms in irritable bowel syndrome with diarrhea in multiple randomized controlled trials.  Further, cyclic therapy has proven to be effective, and intermittent treatment can result in prolonged relief of symptoms.  In this patients case, prior treatment with Xifaxan resulted in symptom improvement.  Based upon the medical literature, the requested Xifaxan  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 Harvoni for treatment of his hepatitis C.  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver related comorbid conditions.  The current guidelines support treatment with Harvoni for this treatment-naive patient with early stage disease, without cirrhosis.  All told, the requested medication Harvoni is medically indicated for the treatment of this patient.  Final Result:  Two reviewers determined that requested medication 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Nature-Throid for treatment of the enrollees hypothyroidism. The physician reviewer found that neither Armour Thyroid nor Nature Throid is standard, U.S. Food and Drug Administration (FDA) approved treatment for hypothyroidism. In addition, the most recent guidelines of the major endocrine societies do not recommend use of thyroid hormone extracts to treat hypothyroidism. This patients records do not include laboratory results that suggest an adverse reaction to the Armour Thyroid was due to an inappropriate dose of the medication that may have resulted in high serum levels of T4 or T3. Therefore, the appropriate treatment for this patient would be levothyroxine with proper monitoring with thyroid function tests in order to titrate the patients dose. All told, the requested Nature Throid is not supported as medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in pediatric endocrinology 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 Norco for treatment of her neck and back pain and headaches. The physician reviewer found that the submitted documentation fails to establish the medical necessity for the requested medication. A review of published studies found no data to suggest that either short acting opioids or long acting opioids are generally more efficacious for treating any particular chronic non-cancer pain condition. In addition, the article by Obermann and colleagues on pharmacotherapy options for cluster headache (CH) notes International treatment recommendations and official guidelines give reassurance about specific pharmacotherapy options for CH, but only few of these are backed by sufficient scientific evidence. In this case, the patient has a history of longstanding chronic neck pain, low back pain and headaches. The patients provider has recommended multi-modal therapies to include imaging and physical therapy. However, according to the documentation submitted for review, there is a lack of documentation demonstrating that the patient has tried and failed the multi-modal therapies recommended. All told, the medical necessity of the requested medication has not been established in this clinical setting.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Three physician reviewers found that in this patients case, the services at issue were likely to have been superior over other available modalities.  The current medical evidence supports the services at issue in this clinical setting.  The data demonstrates advantage when breast tomosynthesis is used.  The addition of breast tomosynthesis to screening mammogram has been associated with an increased rate of detection of small cancers, especially in patients with dense or heterogeneously dense breast tissue.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluation.  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: 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 myRisk genetic testing for evaluation of the enrollees breast cancer status post bilateral mastectomy. Two physician reviewers found that screening for BRCA mutations is indicated in patients whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying those who carry these mutations has clinical importance since it mandates the adoption of special measures aimed at risk reduction. Well-established guidelines identify those patients in whom genetic screening is warranted. This patient reports a history of invasive ductal breast cancer, and also reports two close relatives diagnosed with pancreatic cancer. As per National Comprehensive Cancer Network (NCCN) guidelines, she is as such eligible for  BRCA1 and BRCA2 testing. However, additional genetic tests included in the myRisk panel are not indicated. Therefore, the use of the myRisk genetic testing was not 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 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 clinical genetics and clinical biochemical genetics and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a full body positron emission tomography (PET) scan for medical evaluation of her cancer.   Findings:  Three physician reviewers found that at the recommendation of the National Oncology PET Registry, the Centers for Medicare and Medicaid Services (CMS) revised its recommendation for coverage for PET scans in patients with nearly every type of solid tumor.   The full body PET scan was within the revised CMS guidelines and was likely to have been more beneficial than any available standard imaging modality.  Final Result:  Three reviewers have 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:  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Two physician reviewers found that when it comes to recommendations for treatment-naive chronic hepatitis C virus patients with genotype 1a, the national guidelines recommend daily Harvoni. Moreover, this patient has an extrahepatic manifestation of chronic hepatitis C virus, which is lymphoma. Hence, treatment is critical and should be prioritized as emergent. Accordingly, the requested course of treatment with Harvoni is supported as medically necessary. Final Result: Two 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: All three reviewers 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested a secondary cranial helmet for treatment of the enrollees deformational plagiocephaly. The physician reviewer found that in this case, the secondary cranial helmet was medically necessary for treatment of the patients plagiocephaly. The use of molding helmets is the standard therapy for children with plagiocephaly. Plagiocephaly, if left untreated, can be associated with significant psychogenic, ocular, and oral occlusion problems. There is support in the medical literature of the effectiveness of the molding helmet for treating children with plagiocephaly. An infants head growth tapers off rapidly from 6 to 12 months of age, and it is preferable to initiate a molding helmet before five months of age. In this case, the patient presented with an initial asymmetry and was provided with a cranial helmet. Two months later the patients head asymmetry had been reduced. A second helmet was recommended due to the tightness of the original helmet as the patient still presented with plagiocephaly. As such, the patients molding helmet therapy was incomplete and a second helmet was medically necessary to complete the molding therapy. Therefore, based on the medical literature cited above and the documentation submitted for review, the secondary cranial helmet was medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the device at issue was 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 pediatrics with sub-specialty certification in neurodevelopmental disabilities 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.