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 medical treatment of her hepatitis C.  Findings:  Three physician reviewers found that per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Treating patients with early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from advanced disease.  All told, the requested Harvoni is medically indicated for the treatment of this patient.  Final Result:  Three reviewers have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Sovaldi and Olysio for treatment of his hepatitis C virus genotype 1a.   Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Overall, the data supports treatment in all hepatitis C virus infected persons, except those with limited life expectancy due to non-liver-related comorbid conditions. Consistent with the current FDA recommendation, the combination of Sovaldi and Olysio should be approved for 12 weeks in this patient. Thus, the requested 12 week course of Sovaldi and Olysio is supported as medically necessary for treatment of this patients hepatitis C virus infection.   Final Result: Three  reviewers concluded that the requested medications are medically necessary for treatment of the enrollees medical condition.  Because all three physician reviewers concluded that the requested medications are medically necessary for treatment of the enrollees medical condition, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology.   Physician reviewer number two is actively practicing and is board certified in internal medicine with sub-specialty certification in gastroenterology. Physician reviewer number three is actively practicing and is board certified in internal medicine with sub-specialty certification in gastroenterology.  All three reviewers are knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented to the emergency room with sciatica and severe low back pain with a pain rating of 7/10. There are numerous serious possibilities that could have been causing these symptoms including disc herniation with compressive neuropathy, spinal cord compression, malignant tumor, paraspinal infection, and others. Undiagnosed pathology could lead to permanent weakness, foot drop, paralysis, and other serious medical problems. The severe nature of the patients symptoms, the failure of outpatient treatment, and the potential for serious complications were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily functions. In sum, the services met prudent layperson criteria for emergency care.  Final Result:  The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency medicine is actively practicing. The reviewer is knowledgeable in the treatment of the enrollees medical condition, the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested abdominoplasty/diastasis recti repair to be performed at the same time as a ventral hernia repair for the treatment of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested abdominoplasty/diastasis recti repair.  In this patients case, the records document an umbilical hernia and diastasis recti.  The repair of diastasis recti is not generally considered to be a functional treatment but can be an integral part to cosmetic procedures, namely abdominoplasty.  Coriddi and colleagues evaluated functional status following abdominoplasty and noted that rectus plication did not significantly improve functional outcomes.  This patient does have an umbilical hernia, and the Health Plan has approved coverage for hernia repair.  The hernia repair is medically necessary, as this has the potential to become incarcerated and could present a medical urgency or emergency.  However, there is a lack of evidence indicating that repair of diastasis recti can enhance an umbilical hernia repair.  The photograph provided does not support that this is a severe condition related to the rectus diastasis.   In addition, there does not appear to be a significant pannus to suggest that there is a functional deficit related to this, such as chronic intertrigo, ulcerations and/or lower back pain related to the size of an overhanging pannus. Thus, the requested abdominoplasty/diastasis recti repair is not medically indicated for the treatment of this patient. Final Result:  The reviewer determined that the requested services are not reconstructive in nature 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 plastic surgery and is actively practicing. The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested emergency room services on an emergent basis.  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. In this case, the patient presented with severe lower back pain with a pain rating of 8/10 that was keeping her from performing routine activities of daily living. She attempted and failed outpatient care and had seen her primary care provider prior, and was advised to seek emergency evaluation if the symptoms worsened. At the emergency room the patient was evaluated with advanced imaging for the patients potentially serious and disabling condition. The fact that immediate surgical decompression was not performed does not mitigate the fact that there was significant pain and potential for long-term disability. The patients symptoms were of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily functions. In sum, the services met prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni 90 mg/400 mg tablets for 12 weeks for medical treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested 12 week course of Harvoni should be approved as medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested Simponi 50 mg subcutaneous (SQ) monthly for medical treatment of her rheumatoid arthritis. Findings:  The physician reviewer found that Simponi is a well-established, U.S. Food and Drug Administration (FDA) approved medication for the treatment of rheumatoid arthritis. In addition, the authors found that at 160 weeks, 57-67% of patients who continued with Simponi after discontinuing a previous TNF inhibitor treatment experienced sustained improvement in signs, symptoms, and physical function. Since this patient has failed Humira, treatment with the requested Simponi 50 mg SQ monthly is medically necessary.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested speech therapy at the frequency of two times per week (one hour per session) for treatment of the enrollees mixed receptive-expressive language disorder and autism spectrum disorder.  Findings:  The physician reviewer found that speech therapy is medically indicated for children with autism spectrum disorders (Myers and Johnson). This patient has been diagnosed with autism. Given that she has made progress with two hours of speech therapy per week thus far, a reduction in services would be detrimental for this patient. For the reasons provided, it is medically necessary for this patient to have speech therapy at the frequency of two times per week (one hour per session).
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

A female enrollee requested digital breast tomosynthesis (77063) for medical evaluation of her medical condition.  Findings:  Three physician reviewers found that per the medical evidence, the addition of breast tomosynthesis to digital breast mammography has been associated with a decrease in call backs and increased detection of small cancers.  The digital breast tomosynthesis was likely to have been superior over other methods of evaluating this patient.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A female enrollee requested magnetic resonance imaging (MRI) of the right knee for medical evaluation of her knee pain. Findings:  The physician reviewer found that the medical records submitted for review do not demonstrate any physical exam findings of joint looseness or tendon impingement. In addition, there is no documentation of a course of physical therapy that has been tried and failed. The medical records also do not indicate a trial of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen for three or more weeks, which is an accepted standard of care treatment prior to an MRI study being performed. Based on the clinical documentation submitted for review, the medical necessity for the MRI of the right knee has not been established.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested a 12 week course of Harvoni for medical treatment of his hepatitis C virus.  Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines for managing and treating patients with HCV state the following,  Immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C.  Per the treatment guidelines, Harvoni for 12 weeks is medically necessary for this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for medical treatment of her chronic hepatitis C virus.   Findings:  Two physician reviewers 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. These new 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 genotype 1 hepatitis C regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). Treatment of genotype 1 hepatitis C is recommended with daily Harvoni. Moreover, interferon-based regimens are no longer recommended for first-line therapy. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested Harvoni should be approved as medically necessary for treatment of this patients medical condition.   Final Result:  Two reviewers have determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Viekira Pak for medical treatment of his hepatitis C.  Findings:  Three physician reviewers found that according to the 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 for those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Viekira Pak is medically indicated for the treatment of this patient.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 A female enrollee requested breast tomosynthesis for medical evaluation of her risk for breast cancer.  Findings:  Three physician reviewers found that literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate when used with standard mammographic imaging. Given these findings, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a wearable cardioverter defibrillator for medical treatment of her medical condition. Findings:  The physician reviewer found that the patient sustained a cardiac arrest due to ventricular fibrillation in the setting of infection.  The patients active infection precluded immediate defibrillator device implantation.  Therefore, the use of a wearable cardioverter/defibrillator was indicated until the patients infection was completely cured and an implantable defibrillator could be scheduled.  All told, the wearable cardioverter defibrillator was medically indicated for the treatment of this patient.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A male enrollee requested Harvoni for medical treatment of his hepatitis C virus.  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) treatment guidelines, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions (Class I, Level A recommendation). Moreover, treatment-naive patients are recommended to be treated with Harvoni for 12 weeks (Class I, Level A recommendation). Therefore, the request for Harvoni is medically necessary for treatment of the patients medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

A male enrollee requested a computed tomography (CT) scan of the chest for medical evaluation of his dysphagia, palpitations, and abdominal pain.   Findings:  The physician reviewer found that according to the American College of Radiology (ACR), the appropriate initial radiographic examination after a normal chest x-ray would be a barium esophagram. Following this study, if indicated, the patient should proceed with the endoscopic procedure as recommended by his primary care provider. Only if there is an abnormal finding on EGD or even the esophagram would a CT be considered for evaluation of dysphagia. For these reasons, the requested CT of the chest is not medically necessary for evaluation of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a myoelectric prosthetic arm for the left upper extremity for treatment of his congenital absence of left arm above elbow. The physician reviewer found that the records demonstrate that this patient meets the criteria for the requested myoelectric prosthesis. The patient has an amputation above the wrist, has sufficient ability to control the prosthesis, and the patient is free from interfering comorbidities. In addition, the patient can activate the prosthesis and standard body powered prostheses are insufficient for activities of daily living. Moreover, there are no environmental factors to preclude use of the requested device. In this case there is documentation of concurrent bilateral leg amputation and change in living status which requires more control from the prosthesis for activities of daily living than the current body powered hook prosthesis can deliver. Accordingly, the requested myoelectric prosthetic arm is supported as medically necessary for treatment of this patients medical condition.  Final Result:  The reviewer determined that the requested device 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 orthopedic surgery and is actively practicing.  The reviewer is knowledgeable in the treatment of the enrollees medical condition, knowledgeable about the proposed treatment, and familiar with guidelines and protocols in the area of the treatment under review.   In addition, the reviewer holds a current certification by a recognized American medical specialty board in the area or areas appropriate to the treatment under review.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested reduction mammaplasty surgery for medical treatment of the enrollees hypertrophy of breast.  Findings:  The physician reviewer found that the patient reports back, shoulder and neck pain, as well as shoulder grooving.  Her examination documents findings consistent with significant macromastia.  Per the clinical notes, the patients macromastia is causing functional problems and she is likely to benefit from reduction surgery.  In this case, conservative management is unlikely to provide long-term benefit.  All told, the requested reduction mammoplasty surgery is medically indicated for the treatment of this patient.
Appeal type: Urgent Care
Decision: Upheld Decision of Health Plan

A male enrollee requested air ambulance transport services on an emergent basis.   Findings:  The physician reviewer found that air ambulance is indicated under certain circumstances. However, in such circumstances, the transport is covered to the closest facility capable of providing adequate care. This patient was not transferred to the closest facility capable of providing care. Although the patient required continued care in a rehabilitation facility, his transfer there was not emergent or urgent, and was scheduled in advance.  Further, there is a lack of evidence in the literature that any one particular institution is required for the treatment of a particular patient. Thus, a prudent layperson would not have reasonably expected the absence of the air ambulance transport services to have resulted in serious bodily impairment and were not provided on an emergent basis.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

The parent of a female enrollee requested partial hospitalization program (PHP) eating disorder treatment services for medical treatment of the enrollees eating disorder.  Findings:  The physician reviewer found that this patient appears to have made considerable progress while she has been treated at the PHP level of care. The plan is to fully prepare for the step down of this patient so that even if she has some regression, her overall progress will not be threatened, and she will not need to be readmitted to PHP level of care. Given the information in the record, PHP eating disorder treatment services were and are medically necessary for treatment of this patients medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

A female enrollee requested a 24-week course of Sovaldi 400mg (once a day) and ribavirin 600mg (twice per day) for medical treatment of her hepatitis C. Findings:  Two physician reviewers found that the American Association for the Study of Liver Diseases and Infectious Diseases Society of America note that the evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  The requested 24-week course of Sovaldi 400mg (once a day) and ribavirin 600mg (twice per day) is medically indicated for the treatment of this patient.