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

An enrollee has requested a 12 week course of Harvoni 90/400 mg tablets for treatment of his hepatitis C virus.  Nature of Statutory Criteria/Case Summary: Three physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. 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. Therefore, the patient should be approved for Harvoni for 12 weeks to prevent further development and progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term. The patient already has F2 fibrosis, delaying treatment in this case would result in further progression of fibrosis. Final Result: All 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested hip arthroscopy with acetabuloplasty and labral repair for treatment of her hip pain and bone spur.   The physician reviewer found that review of the submitted documentation and relevant literature demonstrates the medical necessity of the requested services. Based on the documentation submitted for review, the patient has documented objective changes of the left hip supporting a diagnosis of a pincher type of acetabular impingement with joint space narrowing and a superior osteophyte. The rationale for the appropriateness of arthroscopic acetabuloplasty is to either postpone or obviate the need for total hip replacement. This is particularly important in an otherwise healthy patient. The accepted incidence of revision arthroplasty after total hip replacement is at least 5% in five years. It is known that total hip replacement will subject the patient to a particulate load of wear debris and patients variably respond to this phenomenon. For these reasons as well as the careful work-up and assessments documented, it is medically necessary for this patient to have the proposed operative procedures. This includes the arthroscopic debridement of the trochanteric bursa and the arthroscopic release of the iliotibial band. In this case, the application of arthroscopic techniques to extra-articular pathology is an appropriate application of these surgical techniques. In sum, hip arthroscopy with acetabuloplasty and labral repair 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, all patients with chronic active hepatitis C virus (HCV) are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. AASLD/IDSA guidelines further state that 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. 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. Therefore, as per the FDA recommendation, the patient should be approved for Harvoni for 12 weeks to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver  disease. 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two 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 conditions.  In treatment-naive patients with hepatitis C, genotype 1 infection, therapy with Harvoni for 12 weeks is recommended.  It is advantageous to treat patients before they progress to cirrhosis.  Based on evidence of safety and efficacy in the published literature, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  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. 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 12 weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that the proposed treatment is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 1. In addition, treatment with Harvoni is expected to be beneficial by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. As per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment 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. Therefore, the patient should be approved for Harvoni for 12 weeks to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease. 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: Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. One reviewer is board certified 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested percutaneous tibial nerve stimulation for treatment of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the requested services in this clinical setting.  Percutaneous tibial nerve stimulation is considered a standard third-line treatment option for overactive bladder per current guidelines.  In this case, the records provided do not indicate that the patient has failed first-line and second-line treatment options for overactive bladder. Therefore, the requested percutaneous tibial nerve stimulation is not likely to be superior over other treatment modalities.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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Norco for treatment of his pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound.  The current standard of care for chronic pain is treatment in a multidisciplinary pain management practice to include physical therapy, massage therapy, cognitive behavioral therapy, and injections to help reduce pain.  The current medical evidence does not support the requested medication in this clinical setting.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  High-dose and short-acting opiates may also cause adverse outcomes.  Ballantyne and Mao reported that prolonged use of opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy.  All told, the requested medication Norco 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Supartz injections for treatment of his osteoarthritis.   The physician reviewer found that carefully conducted double-blinded studies published in the medical literature do not demonstrate any clinical effect from hyaluronan injections. In addition, there is a recognized incidence of aseptic inflammatory reactions due to allergic response and risk of iatrogenic infection within the joint. A recent meta-analysis of the efficacy of viscosupplementation concluded after review of a total of 89 trials involving 12,667 patients with knee osteoarthritis that viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects. Several studies evaluating repeated treatment protocols have reported adverse events including inflammatory changes within the knee joint. Further, the risk of sensitization is expected to increase after repeated exposure to an antigenic substance. All told, the requested Supartz injections are not supported as medically necessary for treatment of this patients degenerative joint disease.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast reduction surgery for treatment of her hypertrophy of breasts.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has the classic symptoms for macromastia. Symptomatic macromastia is a mechanical problem, and conservative treatments have been shown to be ineffective for this condition.  Nonoperative treatments are unlikely to improve her pain.  Per the medical literature, breast reduction has been demonstrated to be curative for symptomatic macromastia, and peer-reviewed studies confirm the benefit of breast reduction surgery for women with upper torso pain due to breast hypertrophy.  All told, the requested breast reduction surgery 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an electric mobility chair for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The available records do not establish that the patient would be bed or chair confined without a power mobility device.  The records indicate that the patients strength has been intact to mildly impaired and not unaddressable by strength training and exercise.  She does not have neurological, musculoskeletal, cardiopulmonary or other organ system impairments that would preclude her from using appropriate assistive devices or an optimally configured manual wheelchair to accomplish her mobility-related activities of daily living.  Physical activity, moreover, is generally appropriate and recommended for conditions such as diabetes, morbid obesity, osteoarthritis, chronic widespread pain, and for general musculoskeletal health.  Manual wheelchair use has been shown to provide significant health benefits over power wheelchair use for persons with mobility impairments.  All told, the requested electric mobility chair is not medically indicated for the treatment of this patient.   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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested Alinia for treatment of the enrollees bacterial overgrowth.  The physician reviewer found that small intestinal bacterial overgrowth is a difficult condition to reliably diagnose and treat. There have been several studies showing some effectiveness of broad-spectrum or poorly absorbed antibiotics, such as metronidazole, trimethoprim-sulfamethoxazole, and rifaximin, in this condition. However, there is a lack of evidence that Alinia has a role in the management of small intestinal bacterial overgrowth. Alinia is useful in the treatment of intestinal infection with pathogens such as Giardia lamblia, Cryptosporidium parvum, and a variety of other intestinal parasites. Alinia is also being actively studied as a treatment for viral infections, including some which affect the gastrointestinal tract. This patients records do not include documentation of Giardia lamblia, Cryptosporidium parvum, or other intestinal parasites that are considered indications for Alinia. For these reasons, the requested Alinia 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 pediatric gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the hands for evaluation of his hand pain.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the clinical setting of trauma, where an obvious cause is not apparent, MRI may be beneficial in detecting occult fractures or contusions.   Similarly, where there is a specific tendon injury or localized symptoms, MRI will provide the best imaging available.  Other etiologies, including tumors, cysts, and infection also may be appropriately evaluated with MRI.  Per the medical evidence, MRI has also been helpful in the early diagnosis of rheumatoid arthritis.  However, in this patients case, the records do not support the requested services.  His pain is not reportedly localized.  The records indicate that his pain is bilateral.  There are no reported objective signs, and there is no indication of a systemic arthritis.  An MRI is not appropriate in this clinical setting of generalized pain and is not likely to alter the patients treatment.  All told, the requested MRI of the hands 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment services for treatment of his behavioral health conditions. The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients illness burden had necessitated three acute admissions in the preceding two months.  Further, an attempt at the intermediary setting of partial hospitalization was unsuccessful.  His alcoholism dominated his daily routine, negatively impacted his relationships and caused significant impairment across multiple domains of functionality.  His social and living environments as arranged were unable to support sober living.  Further, the patient had multiple co-occurring psychiatric conditions which compromised his prognosis.  Per the medical records, discharge would have been premature.  He was anxious, disruptive, irritable and isolative.  He was not adequately maintaining his activities of daily living.  He lacked the skills necessary to effectively manage conflict and struggled with self-disclosure.  In this patients case, in the absence of residential programming, he was likely to have promptly relapsed and required re-admission.  All told, residential treatment services 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.