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 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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the guidelines, treatment-naive genotype 1 patients should be treated. This guideline recommendation is 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 is supported as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The physician 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. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication in this patients case.  Both Harvoni and Viekira Pak are equally safe in pregnancy.  However, ribavirin is pregnancy category X.  Thus, the requested medication Harvoni is medically indicated and is appropriate given the Health Plans alternative.  Additionally, the patients cirrhosis will require a 24-week course of Viekira Pak, whereas the desired Harvoni treatment requires 12-week duration of therapy.  There is sufficient support for the requested medication in this clinical setting.  In this patients case, Harvoni  is medically indicated.  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: An enrollee has requested bariatric surgery for treatment of her medical condition.  Findings:  The physician reviewer found that review of the submitted documentation fails to establish the medical necessity of the requested surgery. In this case, the patient presents with weight regain status post gastric bypass procedure. Revision surgery is indicated for documented complications of the original procedure that require surgical intervention to correct. Based on the clinical records submitted for review, there is no documented complication of the original procedure that requires surgical intervention to correct. For the reasons provided, the request for bariatric surgery is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested surgery 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 general 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested pharmacogenetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is a paucity of evidence for the benefits of pharmacogenetic testing in the context of pain management. The medical literature indicates that many studies investigated a possible role of the CYP2D6 polymorphisms on pain sensitivity, pharmacokinetics and pharmacodynamics of these drugs, but the results of analgesia and adverse effects are conflicting. The authors recommend more studies to demonstrate genetically determined unresponsiveness and risk of developing serious adverse events for patients with pain and these should involve larger numbers of patients in different population types. Clinical treatment of the patients condition is based on ongoing practice standards. Pharmacogenetic testing including CYP2D6 testing is not standard practice regarding management decisions involving pain management therapies and the available medical records provided for review does not support that such testing will alter her treatment from standard available therapy.  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:   One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  Two 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued skilled nursing facility services (physical therapy, occupational therapy and speech therapy) for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for continued skilled nursing facility services (physical therapy, occupational therapy and speech therapy) has not been established. According to the documentation submitted for review the patient had a stroke and has been treated at the skilled nursing facility level of care. After receiving skilled nursing facility level therapies, the patient made some slow progress in aspects of self-care while other aspects of self-care and functional mobility showed no improvement. Continued skilled nursing facility level therapies are not supported by the literature or by the patients recovery trajectory. He may benefit from some degree of outpatient therapy, but skilled nursing facility level therapy is not medically necessary. The nursing note does not show a need for inpatient level skilled nursing care. The patient does have basic care needs that can be addressed by home health aides. As such, skilled nursing facility services (physical therapy, occupational therapy and speech therapy) was not and is not medically necessary.  Final Result: The reviewer 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 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 gabapentin for treatment of her medical condition. Findings:  The physician reviewer found that the request for gabapentin is medically necessary for treatment of the patients medical condition. According to researchers, gabapentin is a first-line agent for neuropathic pain. The documentation submitted for review indicates that the patient has a condition of fibromyalgia syndrome for which she is being prescribed gabapentin. The condition of fibromyalgia syndrome is supported for the treatment with gabapentin. As such, gabapentin is supported as medically necessary for the treatment of fibromyalgia syndrome.   Final Result: The reviewer determined that the requested medication dosage 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 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: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested an Amnisure test for the evaluation of her medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  There is no history provided to suggest that this patient had ruptured her membranes, and the record does not indicate that a physical or pelvic examination was performed.  The diagnosis of membrane rupture typically is confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid, which is identified under microscopic evaluation.  In equivocal cases, additional tests may aid in the diagnosis.  Per the submitted documentation, there is nothing in the record to suggest that there was clinical confusion as to the presence or absence of ruptured membranes by physical examination, nitrazine testing, or ferning.  It does not appear that these standard evaluations were performed.  The routine use of Amnisure to diagnose ruptured membranes is not recommended.  Therefore, an Amnisure test was not likely to be superior over other methods of evaluation.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Genomind Brain Science Genetic Testing for evaluation of his medical condition. Findings:  Two physician reviewers found that studies have shown that clinically useful predictors are scarce for antidepressant therapy, and the results are inconsistent.  They have shown that there is only marginal clinical association between enzyme system variants and medication metabolism, efficacy, and tolerability in the treatment of psychiatric illnesses.  There is a lack of large randomized trials supporting the use of genetic testing in this clinical setting.  The existing studies have also indicated that there was no significant correlation between either genotypes or antidepressant serum concentration and response to antidepressant treatment.  The current evidence does not support the use of genotyping when choosing an antidepressant.  Even less is understood about its utility in the treatment of anxiety disorders.  Genetic testing lacks evidence-based research to show its effective use in guiding the provider towards choosing a medication regimen.  Thus, Genomind Brain Science Genetic Testing was not likely to have been of greater benefit than other methods of evaluating this patient.   Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in psychiatry 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 Daklinza to be used in conjunction with Sovaldi and ribavirin for 24 weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the guidelines issued for treatment-naive patients with HCV genotype 3 infection the recommended regimens include daily daclatasvir (Daklinza) and sofosbuvir (Sovaldi) for 12 weeks (no cirrhosis) or 24 weeks with or without weight-based ribavirin (cirrhosis) or daily sofosbuvir (Sovaldi) and weight-based ribavirin plus weekly peg-interferon for 12 weeks for interferon-eligible, patients. The alternative regimen for treatment-naive patients with HCV genotype 3 infection includes daily sofosbuvir (Sovaldi) and ribavirin for 24 weeks for patients who are interferon-ineligible. The providers proposed treatment of Daklinza, Sovaldi and ribavirin for 24 weeks is a Class IIa, Level C recommendation. However, the Health Plans approved option of Sovaldi and ribavirin for 24 weeks is a Class 1, Level A recommendation. Thus, per the guidelines, the Health Plans approved option is more highly rated than the providers treatment option. As such, based on nationally-recognized guidelines the request for Daklinza to be used in conjunction with Sovaldi and ribavirin for 24 weeks is not medically necessary.  Final Result: The reviewer determined that the requested medications 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 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 medical condition.   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 limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus (HCV) NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` 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: Upheld 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 guidelines issued, 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 non-cirrhotic genotype 1 patients should be treated with Harvoni, or with Viekira Pak and ribavirin.  These guideline recommendations are based on multiple randomized clinical trials.  Although treatment of hepatitis C is necessary, based on medical literature, the information supplied in this case does not provide justification to support coverage of Harvoni over Viekira/ribavirin. No head-to-head clinical trials have compared these medications, and the patient does not have anemia, pregnancy, or other contraindications to ribavirin. Concern for Viekira-induced hepatic decompensation in cirrhotic patients does not apply to this non-cirrhotic patient.  For these reasons, the requested treatment with Harvoni is not supported as medically necessary for the treatment of this patients hepatitis C infection.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  As noted, breast tomosynthesis has the potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  Medical terminology noted that the addition of tomosynthesis to digital mammography was associated with a decrease in recall rate and an increase in cancer detection rate.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, three-dimensional breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three physician 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 physician 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 hepatitis C virus (HCV).  Findings: The physician reviewer found that according to the guidelines 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. Harvoni is a fixed-dose combination of ledipasvir, a hepatitis C virus NS5A inhibitor, and sofosbuvir, an HCV nucleotide analog NS5B polymerase inhibitor. The drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. Per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` 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.