Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Afirma Gene Expression Classifier test evaluation of her thyroid nodule.  Findings:  Three physician reviewers found that molecular testing has been proposed by the American Thyroid Association (ATA) as an adjuvant in medical decision making of whether to refer a patient for thyroidectomy. The ATA guidelines state For nodules with [atypia of undetermined significance/follicular lesion of undetermined significance] AUS/FLUS cytology, after consideration of worrisome clinical and sonographic features, investigations such as repeat FNA or molecular testing may be used to supplement malignancy risk assessment in lieu of proceeding directly with a strategy of either surveillance or diagnostic surgery. Informed patient preference and feasibility should be considered in clinical decision-making. In this case, the patient had multiple biopsies with indeterminate results. Thus, the submission of the specimen to Afirma gene expression classifier was appropriate. A benign result would have prevented unnecessary surgery in this patient. The rate of unnecessary surgeries and associated morbidity has decreased with the use of molecular testing. In this case the decision to refer the biopsy specimen to Afirma testing was appropriate. All told, the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the testing at issue was likely to be more beneficial for evaluation and treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Two physician reviewers are board certified in endocrinology and metabolism and are actively practicing. One physician reviewer is board certified in oncology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin 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 guidelines, genotype 2 patients should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 2 regardless of fibrosis stage. AASLD guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, Harvoni is first-line therapy for treatment-naive genotype 1 patients. Non-cirrhotic patients with viral load below 6,000,000 IU/mL can be treated with Harvoni for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  For these reasons, the requested treatment with Harvoni is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 guidelines issued state that 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 guidelines, treatment-naive non-cirrhotic genotype 1 patients should be treated with Harvoni for 12 weeks or with Viekira Pak and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Because treatment of hepatitis C is medically necessary based on medical literature, and no alternative treatment has been approved at this time, 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: 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 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. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with a viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. In addition, the 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 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 eight weeks for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. A report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines. 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 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 virus. Findings:  The physician reviewer found that the requested treatment is medically necessary and is considered the standard of care for the treatment of patients with chronic hepatitis C. According to the guidelines 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. In addition, guidelines state that high priority for treatment owing to high risk for complications includes patients with a Metavir of F2. In this case, the patient has a Metavir of F2; hence, treatment is indicated. Therefore, per the national guidelines Harvoni is medically necessary.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 percutaneous tibial nerve stimulation (PTNS) for treatment of her medical condition. Findings:  Two physician reviewers found that PTNS was likely to be more effective for this patient than other available options. According to the American Urological Association (AUA) guidelines for the treatment of overactive bladder, PTNS is considered an acceptable third-line treatment option when first-line and second-line options have been tried and failed. In this case, both first and second-line treatments have failed, and treatment with PTNS was clinically indicated and appropriate. Therefore, the services at issue were likely to be more beneficial than standard medical therapy in this clinical setting.Final Result: The 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: Reviewers 1, 2, and 3 are board certified in urology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Copaxone for treatment of his multiple sclerosis. Findings: The physician reviewer found that Copaxone (glatiramer acetate) is medically necessary for treatment of the patients medical condition. Copaxone is U.S. Food and Drug Administration (FDA) approved for relapsing forms of MS. Copaxone has been studied against placebo and was found to be safe and effective. Given that Copaxone FDA approved for relapsing forms of MS and the support in the peer-reviewed literature, the requested medication is medically necessary.  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 neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan for treatment of his medical condition. Findings:  The physician reviewer found that the patient is currently receiving treatment for the conditions of systemic lupus erythematosus and retroperitoneal fibrosis.  The available medical records do not document clear provider rationale for treatment with Rituxan.  The requested medication Rituxan has been approved for the treatment of rheumatoid arthritis, vasculitis (Wegeners granulomatosis and microscopic polyangiitis), lymphoma and leukemia.  The available medical records do not document the presence of any of these diagnoses.  All told, Rituxan is not medically indicated for the treatment of this patient.  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 rheumatology 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 magnetic resonance imaging (MRI) guided focal laser ablation of prostate cancer for treatment of his medical condition.  Findings:  Three physician reviewers found that the use of focal therapy of prostate cancer is not considered standard of care by the majority of urologists.  The medical guidelines do not comment on utilization of focal therapy for treatment of prostate cancer.  Many forms of energy are utilized to provide focal therapy. Only a few studies have evaluated the efficacy of MRI guided laser therapy for the treatment of prostate cancer.  These are phase 1 studies involving a small number of patients. The criteria for successful treatment are largely unknown, and there is a lack of long-term follow-up available.  All told, MRI guided focal laser ablation of prostate cancer was not likely to have been superior over other treatment options.  Final Result:  Three reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested automated nerve conduction testing for treatment of her medical condition. Findings:  Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There is a lack of scientific, large number automated nerve conduction testing studies in the peer-reviewed literature showing its safety and effectiveness. There are smaller studies which have questioned its validity and efficacy. All told, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  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 neurological 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 residential mental health and substance use treatment for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patients alcohol use permeated multiple functional domains.  Further compromising the clinical picture was the presence of a comorbid depressive illness and medical issues.  The record reflects that the patient had not consolidated the treatment gains necessary to succeed independently.  The patients primary support system was crumbling.  Her primary coping mechanism for most of her adult life had been drinking.  Based on these factors, it was likely that the patient would have promptly relapsed and required re-admission in the absence of residential programming.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  Additionally, the treatment course seamlessly transitioned to a comprehensive community-based program rather than a hasty discharge with a break in care.  Considering the clinical presentation and perusal of the peer-reviewed literature, the services at issue were medically indicated for the treatment of this patient.Final Result: The reviewer determined that the services at issue were 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 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 acupuncture services for treatment of her medical condition.  Findings:  The physician reviewer found that while studies on the effects of acupuncture for the treatment of foot pain are limited, there is data supporting the use of acupuncture as an effective modality for those experiencing chronic pain. A paper noted that significant differences in results between true and sham acupuncture, which indicates acupuncture is more than a placebo. In this patients case, review of the submitted clinical documentation demonstrates that the patient has undergone multiple attempts at treatment of her foot pain without benefit. According to the submitted documentation, the patient continues to experience severe symptoms and impairment of her daily activities secondary to her unrelieved foot pain. As such, acupuncture is medically reasonable and appropriate to attempt to manage the patients pain and improve function. Therefore, the requested acupuncture services are 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 reviewer is board certified in oriental 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.