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 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. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni. 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. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a collagen meniscus implant (CMI) for treatment of his medical condition.  Findings: Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  Clinical examination findings did not evidence positive meniscal signs, and there was no documentation of mechanical symptoms. There was imaging evidence of prior medial meniscectomy, and additional tearing could not be excluded. There was also imaging evidence of mild degenerative osteoarthritis, greatest in the medial compartment. There is no indication to support additional meniscal surgery at this time. Therefore, the requested services are not likely to be of greater benefit than other treatment alternatives.  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: All three physician reviewers are board certified in orthopedic surgery 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. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related conditions. For treatment-naive or treatment-experienced patients with genotype 6 hepatitis C, the guidelines recommend Harvoni for 12 weeks. This is based on both in vitro data and clinical trial results showing 96% sustained virologic response after 12 weeks of therapy (Wong, et al; Kohler, et al). AASLD guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   Findings:  Three physician reviewers found that per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard therapy.  Final Result: Three reviewers determined that the service 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 Bydureon for treatment of her medical condition.  Findings: The physician reviewer found that Bydureon is a member of the glucagon-like peptide 1 (GLP-1) analogues, a class of drugs used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional beneficial of Bydureon relates to potential improvements in beta cell function. By treating patients with Bydureon relatively early in the course of diabetes, one may be able preserve beta cell function for the long-term and slow down the progression of diabetes. Another benefit of Bydureon is its potential for weight loss in contrast to the medications which the patient is currently taking, which are expected to be weight-neutral or possibly promote weight gain. Given this support, the requested Bydureon is medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication is necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Qualifications/Credentials: The physician 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging (MRI) of the right knee for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Obtaining an MRI without correlation with a detailed clinical examination can lead to unnecessary surgery.  In this particular patient, her provider did not feel that an MRI was indicated.  Her physical examination did not support a meniscal tear or a ligamentous injury or tear, and a surgical intervention would not change the course of treatment.  In sum, the requested MRI of the right knee is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology 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 continued acute hospital stay for treatment of her medical condition. Findings:  The physician reviewer found that the records do not support continued acute hospital stay services as medically necessary for treatment of this patients medical condition. The Centers for Medicare and Medicaid (CMS) guidelines for acute hospital care require physician certification of the medical necessity that such services be provided on an inpatient basis. This patients physicians have been stating that she is medically stable for discharge. There is no indication for additional inpatient care. Reviewing the records, the patient is ready to transfer to skilled nursing facility level rehabilitation and the requested continued acute care services are not medically necessary.  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 neuromuscular medicine and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the iSpot cell function assay test for evaluation of her medical condition.   Findings: Three physician reviewers found that the iSpot test is not currently considered the standard of care for diagnosis of Lyme disease. The standard approach based on guidelines is to obtain an antibody test then conduct Western Blot testing for confirmation. In this case, the Western Blot was negative before the iSpot test was done. Western Blot analysis is beneficial because it can detect and discriminate among antibodies to multiple antigens of Borrelia burgdorferi.  Thus, the iSpot cell function assay testing was not likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: All 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:   All three reviewers are board certified in internal medicine with sub-specialty certification in infectious diseases 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 Latuda for treatment of her behavioral health condition. Findings:  The physician reviewer found that Latuda is an atypical antipsychotic agent initially approved by the United States Food and Drug Administration (FDA) for the treatment of schizophrenia, subsequently Latuda gained an additional indication for the treatment of bipolar illness. Although Latuda has demonstrated preliminary positive outcomes for mixed depression, the lack of additional well-designed, adequately-powered replicative studies demonstrating safety and efficacy tempers the value of these initial findings. Further, Latuda is not FDA approved for major depressive disorder nor recommended by the most recently published clinical practice guideline for treatment of unilateral depressive illness. Considering that the patient has not been treated with and failed well-established augmentative strategies, such as buspirone, quetiapine, olanzapine-fluoxetine, lithium or thyroid hormone, the requested Latuda is not 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 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 residential treatment center (RTC) services for treatment of his medical condition.   Findings: The physician reviewer found that although addiction specialty services and psychiatric care remained indicated, the clinical documentation does not demonstrate the medical necessity of treatment in a 24-hour supervised setting. The patient embraced recovery principles and expressed motivation for treatment. The patient was sleeping well and had no safety concerns or evidence of an acute psychiatric syndrome. Additionally, there was no evidence to suggest that a less restrictive treatment setting would have been insufficient. All told, the RTC rehabilitation services were not medically necessary for treatment of the patients behavioral health 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 physician 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 a peripheral nerve stimulator for treatment of his medical condition.   Findings: The physician reviewer found that while the medical literature supports the use of peripheral nerve stimulator for treatment of chronic cluster headaches and chronic migraines, there is limited data regarding its use for treatment of cervicogenic or post traumatic headaches, such as is the case with this patient. Moreover, there are some studies that identify complications with the implanted nerve stimulator related to lead placement and lead migration. In this patients case, there are other therapeutic options for the treatment of daily headaches that have not been tried and failed. Therefore, in light of the scientific literature and the submitted medical records, the medical necessity of the requested peripheral nerve stimulator has not been established.  Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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 Anser IFX testing for evaluation of his medical condition.   Findings:  Three physician reviewers found that the use of Anser IFX to direct management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials of patients with inflammatory bowel disease. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have clear Remicade levels been established. Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response. Another study concluded that prospective evaluation of the value of measuring serum concentrations of infliximab should be performed before these data can be included in patient management strategies. One study, with some patients undergoing dose intensification following initial non-response, showed no difference in serum levels of infliximab between patients who responded to dose intensification versus those who did not. Although loss of response to infliximab is common, there were no standard guidelines defining a therapeutic strategy at the time of testing. A systematic review reported that future prospective controlled studies are needed, especially considering that anti-TNF levels are influenced by several variables that can fluctuate over time and among individuals. Based on the scientific literature, the Anser IFX for the evaluation and management of this patients medical condition was not likely to be more beneficial than available standard therapy.  Final Result: All 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:  All three physician 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 balloon sinuplasty for treatment of his medical condition. Findings: Three physician reviewers found that chronic rhinosinusitis is clinically defined as symptomatic involvement of the paranasal sinuses with complaints of facial pain, pressure, discolored anterior and posterior nasal drainage and discharge along with associated symptoms of low-grade fever usually lasting more than 12 weeks unrelieved with appropriate medical management with nasal irrigation techniques, antibiotics, adjunctive therapies including topical nasal steroids and objective documentation based on computed tomography (CT) imaging showing mucous membrane changes within the paranasal sinuses. In this case, the patient does not meet clinical criteria as the records submitted showed that the CT scan to be relatively normal with only very minimal membrane thickening within one paranasal sinus. In sum, clinical indications for sinus surgery have not been met. As such, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: All 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 otolaryngology 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 abdominoplasty and incisional hernia surgery for treatment of her medical condition.  Findings: The physician reviewer found that the request for abdominoplasty is medically necessary for treatment of the patients medical condition. Based on the medical documentation provided, she has a significantly abnormal condition of the upper and lower abdomen as well as  a severe bulge of the upper abdomen consistent with a large incisional hernia and a significantly overlapping lower abdominal pannus.  There is support in the medical literature for performing the procedures concurrently. The patient has indications for both procedures as the abdominoplasty approach can provide adequate exposure for the repair of the large incisional hernia and to allow for resolution of her abdominal excess. Thus, an abdominoplasty approach in this patient satisfies medical necessity as a combined procedure with concurrent treatment of her hernia. All told, the incisional hernia surgery performed at the same time as the requested abdominoplasty is medically necessary for 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 physician reviewer is board certified in plastic 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.