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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Viekira Pak or Harvoni for treatment of his hepatitis C virus (HCV).  Findings: Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, patients with chronic active hepatitis C are eligible for treatment and should be treated with FDA approved antiviral therapy regardless of fibrosis score. Moreover, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Thus, the goal of treatment of HCV-infected persons is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Treatment with Harvoni improves patient-related outcomes across a range of domains, included health-related quality of life, vitality, fatigue, and work productivity. Moreover, treatment with Viekira Pak has been associated with high rates of SVR among previously untreated patients with HCV genotype 1 infection . Thus, the request for Harvoni or Viekira Pak is medically necessary for treatment of this patients medical condition. Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The 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 Botox injection for treatment of her migraines. The physician reviewer found that the records indicate that this patient has chronic headaches, but there is inadequate documentation to support a diagnosis of chronic migraine. Given the patients medications including Vicodin and Fiorinal, it is likely that she has medication overuse headache. However, the patients use of Vicodin and Fiorinal are not specified in the records provided for review to establish whether her headaches are due to medication overuse. In addition, there is a lack of documentation of an adequate trial with preventive therapies, or the use of triptan. Given these findings, the requested Botox is not medically necessary for treatment of this patients headaches. Final Result: The reviewer determined that the requested therapy 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the services at issue were not likely to have been more effective than other alternatives.  There is a lack of support for the bilateral breast tomosynthesis in this clinical setting.  The medical records do not indicate an increased risk of breast cancer.  Although breast tomosynthesis is a promising technique, the superior efficacy of bilateral breast tomosynthesis has not been established.  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 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 residential treatment services for treatment of his alcohol abuse.   The physician reviewer found that this patient does not meet criteria for residential level of care. He is cooperative with treatment, is gaining insight, has support from his girlfriend and does not present with any additional medical or significant psychological factors.  He could have safely continued treatment at a lower level of care. Accordingly, residential treatment services were not medically necessary for treatment of this 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C.  Findings:  Three physician reviewers 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, regardless of fibrosis, should be treated, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Patients with cirrhosis are considered highest priority for immediate therapy.  Per the medical evidence, Harvoni is recommended for patients with hepatitis C, genotype 1 and cirrhosis who have failed prior therapy with pegylated interferon and ribavirin.  Based on evidence of safety and efficacy in the literature, the requested medication Harvoni is medically indicated for the treatment of this patient.  Final Result: Three 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The 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 UroLift procedure for treatment of his benign prostatic hyperplasia. Three physician reviewers found that although UroLift received U.S. Food and Drug Administration (FDA) approval, long-term studies and comparative studies with transurethral resection of prostate (TURP) have not been completed or reported. In addition, the current American Urological Association (AUA) guidelines do not recommend UroLift as a treatment option in this clinical setting. Moreover, it is unlikely that the UroLift procedure will provide sufficient relief in this patient with such severe obstruction. For these reasons, the requested UroLift procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard modality.  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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of his Duchenne muscular dystrophy.  The physician reviewer found that durable medical equipment, such as a wheelchair, is important for the function of patients with neuromuscular diseases such as muscular dystrophy. Replacement wheelchairs are expected to be needed over time for users with muscular dystrophy due to equipment wear and tear, which can progress to the point of breakdown. The typical life expectancy of a wheelchair has generally been reported to be up to five years. Despite some advances in technology, improvements in overall wheelchair durability have not been observed. In the current case, the patient has developed progressive weakness due to muscular dystrophy. However, it is has not been established that he can safely operate a power wheelchair independently by lip-control, chin-control or otherwise any longer. Absent the ability to safely and reliably operate the power wheelchair, his needs could be met by an appropriate manual wheelchair. Thus, the requested power wheelchair is not medically necessary based on the available documentation.  Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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

ANature of Statutory Criteria/Case Summary: An enrollee has requested corneal collagen cross-linking with riboflavin for treatment of the enrollees keratoconus. Two physician reviewers found that recently, the U.S. Food and Drug Administration (FDA) indicated that it would recommend approval for the riboflavin compound that is used in corneal cross-linking therapy. The available peer-reviewed medical literature includes studies that demonstrate cross-linking therapy in cases of keratoconus can result in earlier corneal stabilization without having to resort to invasive procedures like penetrating keratoplasty. All told, the corneal collagen cross-linking with riboflavin was likely to have been more beneficial to this patient than the available standard therapy. Final Result:  Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in ophthalmology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an orthopedist specialist opinion for treatment of his right knee condition.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has multiple comorbidities, including diabetes mellitus with peripheral neuropathy, hypertension, and tobacco use disorder.  It is appropriate for the patient to be evaluated by an orthopedic surgeon for an informed discussion of operative and nonoperative management of his documented knee osteoarthritis.  The orthopedic surgeon may be able to offer minimally invasive treatments that could be tolerated by the patient, in addition to recommendations regarding kinesiotherapy, exercise therapies, weight reduction, smoking cessation and a more careful management of diabetes mellitus.  All told, the requested orthopedist specialist opinion is medically indicated for the treatment of this patient.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested physical therapy, occupational therapy and weekly massages for treatment of her medical condition.  The physician reviewer found that the patient sustained major vascular injuries in the left lower limb.  The laceration injuries were complicated by arterial clots further compromising blood flow to the distal left lower limb.  Vascular flow could not be re-established before significant tissue injury occurred.  Sequelae included myonecrosis of the lower leg muscles, compartment syndrome and deep peroneal nerve injury.  Notably, she underwent multiple debridements of the necrotic muscle tissue.  She has had residual left foot drop.  The patient has undergone inpatient and outpatient rehabilitation and has recovered modified independent ambulation using an ankle-foot orthosis and a cane.  She has maintained full passive range of motion and has been performing a home exercise program.  At this time, there are no expected health outcome benefits or functional benefits expected with further physical therapy, occupational therapy or massage therapy.  This patient has achieved maximal medical and functional benefit from therapy services.  She has had sufficient therapy to be independent with a stretching, strengthening and modality/self-massage program for maintenance of range of motion and slowly building up strength and endurance.  This patients clinical course and outcomes are not expected to be marginally improved with the proposed interventions.  All told, the requested physical therapy, occupational therapy and weekly massages are not medically necessary 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 physical medicine and rehabilitation 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 for 12 weeks for treatment of his hepatitis C virus (HCV). Findings:  Three physician reviewers found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. For treatment-naive genotype 1 patients with cirrhosis, AASLD/IDSA guidelines recommend therapy with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug (FDA) approved for genotype 1 hepatitis C regardless of fibrosis stage. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for 12 weeks in this case. Final Result:  Three 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: Two reviewers are board certified in gastroenterology and are actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is 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:   Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Skaane and colleagues compared digital mammography alone and digital mammography plus tomosynthesis in a large prospective screening trial. The authors concluded that 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. Given the support in the medical literature, the use of breast tomosynthesis was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the 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: 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 there is sufficient support for the services at issue in this clinical setting.  Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography.  Breast tomosynthesis has been shown to be most useful in the evaluation of dense breasts.  There are several studies that support the use of breast tomosynthesis as a more accurate study than routine screening mammography.  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.  Rafferty and colleagues noted that the addition of tomosynthesis to digital mammography offers the dual benefit of significantly increased diagnostic accuracy and significantly reduced recall rates for noncancer cases.  In this patients, she has known heterogeneously dense breasts.  All told, breast tomosynthesis was likely to have been superior over other modalities for evaluating this patient.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for an eight week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1a. Findings:  Two physician reviewers found that Harvoni was approved by the U.S. Food and Drug Administration (FDA) for the treatment of chronic hepatitis C genotype 1 infection in both treatment-naive and treatment-experienced patients. 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. FDA approved antiviral therapy regardless of fibrosis score. The recommended treatment duration depends on prior treatment experience and the presence or absence of cirrhosis. The guidelines note that treatment duration of eight weeks can be considered in treatment-naive patients without cirrhosis who have a baseline viral load less than 6 million IU/mL. Since this patient is treatment-naive and has a viral load of less than 6 million IU/mL, the requested eight week course of Harvoni is 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: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. The 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