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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 24 week course of Sovaldi for treatment of his hepatitis C virus (HCV). Findings:  Two physician reviewers found that Sovaldi is medically necessary and is for the treatment of the patients with HCV, genotype 3. In addition, treatment with Sovaldi is expected to be beneficial for this patient by potentially curing HCV infection and preventing damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by U.S. Food and Drug Administration (FDA.) Therefore, Sovaldi is medically necessary for treatment of this patient with HCV genotype 3. 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 whole body skin photography for medical evaluation of her change in mole size.  Findings:  Two physician reviewers found that there is a paucity of evidence that whole body photography is better than serial clinical or dermatoscopic exams. There are several large cohorts that show that whole body photography reduces worry of the patient. However, whole body photography has not been shown conclusively to reduce the incidence of melanoma detection or increase the evidence of early detection. There are several other means by which providers can evaluate moles including dermoscopy and with mole mapping technologies. A patients personal or family history of having melanoma or severely atypical nevi is a better predictor of future melanoma diagnosis. Thus, the use of whole body photography as performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested surgical services and related services on an emergent basis.  Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with chronic pelvic pain secondary to ruptured ovarian cysts and endometriosis and underwent a complex laparoscopic surgery. The operative note documents concern for the severity of the patients pain. Ovarian torsion is considered the most common gynecological emergency. Given the acute severity of the patients pain, abnormal MRI and pelvic ultrasound, a prudent layperson in this circumstance would reasonably believe she was suffering from a serious medical condition. In sum, the patient was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided on the date in question 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 obstetrics and gynecology 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 (HCV). Findings:  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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. In this case, the patient has cirrhosis due to ongoing HCV infection. Therefore, Harvoni is medically necessary to prevent further progression of cirrhosis to decompensated state due to ongoing HCV infection and prevent potential complications of advanced liver disease, long-term such as liver failure requiring liver transplant, and hepatocellular carcinoma. 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. A third 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with a ruptured left breast implant and pain of the left breast. However, this pain was not an acute condition that could reasonably be expected to require immediate medical attention. There is no evidence that a ruptured silicone implant would place the patients health in serious jeopardy, or serious impairment or dysfunction. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, there is no evidence that serious deterioration of the patients health would have occurred if the patient did not have her implants replaced. The patients pain and radiographic work-up are consistent with timely evaluation of her condition. The patient was noted to have had her surgery after a preoperative evaluation. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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 three months for treatment of his chronic hepatitis C virus genotype 1b.  Findings:  Two physician reviewers found that since this patient is genotype 1b, as per the data from the clinical trials and American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Viekira Pak should be used alone and the addition of ribavirin is not recommended. The Health Plan has approved Viekira Pak with ribavirin. Viekira Pak and Harvoni are both considered first-line therapies with similar patient outcomes in terms of sustained virologic response. However, this patients provider has recommended Harvoni to avoid use of ribavirin. For these reasons, the requested Harvoni is medically necessary for treatment of this patients hepatitis C virus genotype 1b infection. 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 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 esophageal manometry with impedance for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patients symptoms, as well as her evaluation that preceded the disputed services, were inconsistent with significant gastroesophageal reflux or esophageal dysmotility.  The current medical evidence does not support the services at issue in this clinical setting.  Indications for esophageal manometry include diagnosis of suspected primary and secondary motility disorders, as preoperative assessment for patients undergoing anti-reflux procedures, and to reassess esophageal functions in patients who have been treated for a primary esophageal disorder or who have undergone anti-reflux surgery.  The disputed testing may be indicated for patients with symptoms of heartburn or nausea after eating or problems swallowing.  In this patients case, the records do not demonstrate the indications for the disputed testing.  All told, esophageal manometry with impedance was not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for 12 weeks for treatment of his chronic hepatitis C virus genotype 1a.  Findings:  Three physician reviewers found that based on the guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA), treatment with direct acting antiviral drugs should be prioritized for patients with the greatest likelihood of achieving benefit with viral eradication. The guidelines note that the highest priority patients include those who are at highest risk of substantial morbidity from untreated hepatitis C virus infection, such as those with advanced fibrosis or compensated fibrosis, transplant recipients, and those with severe extrahepatic manifestations of hepatitis C. High priority patients include those at high risk of fibrosis progression, such as patients with substantial fibrosis as demonstrated by Metavir stage F2, human immunodeficiency virus (HIV) coinfection, coexisting liver disease, or diabetes mellitus. This patient has not demonstrated that he should be categorized as a high priority patient. Accordingly, the requested 12 week course of Harvoni is not supported as medically necessary for treatment of the patients medical condition. Final Result: Three reviewers 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested bilateral breast magnetic resonance imaging (MRI) for evaluation of her lobular carcinoma in situ.  Findings:  Two physician reviewers found that in this patients case, the requested services are not likely to be of greater benefit than other methods of evaluation.  In regards to the management of patients with lobular carcinoma in situ, the medical literature noted that the routine use of MRI does not result in increased cancer detection rates (short-term), nor does it result in earlier stage at diagnosis, illustrating the importance of defining optimal screening strategies for high-risk patients based on tumor biology rather than numerical risk.  The medical literature reported that MRI can detect breast cancer in high-risk patients, but is associated with a significant false-positive rate resulting in unnecessary breast biopsies. More data are needed to define the role of MRI screening for specific high-risk groups.  Since the routine use of breast MRI does not result in increased cancer detection rates for patients, nor does it result in earlier stage at diagnosis, the requested bilateral breast MRI is not likely to be more beneficial for evaluation of this patient than other available options.Final Result: Two reviewers determined that the requested services are 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are an experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the 3D breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. While it is acknowledged that there is a lack of long term studies as of yet proving increased survival rates when tomosynthesis is added to the routine screening mammographic views, the technique has become popular among providers due to the associated decrease in callbacks and increased rate of detection of small cancers. For this reason, the addition of 3D breast tomosynthesis to the usual mammographic films is considered more beneficial for the patient than digital mammography without tomosynthesis.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested three-dimensional (3D) breast tomosynthesis for medical evaluation of her medical condition. Findings:  Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is support in the medical literature for the 3D breast tomosynthesis performed in this clinical setting. The medical literature reported the effect of integrated 2D and 3D mammography in population breast-cancer screening. The medical literature concluded that Integrated 2D and 3D mammography improves breast-cancer detection and has the potential to reduce false positive recalls. Randomized controlled trials are needed to compare integrated 2D and 3D mammography with 2D mammography for breast cancer screening. Although more studies may be needed, there is support in the medical literature supporting the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.Final Result: The reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in diagnostic radiology 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 requested radiofrequency ablation of the tongue base for treatment of his obstructive sleep apnea.  Findings:  The physician reviewer found that according to the documentation submitted for review, this patient has documented obstructive sleep apnea and has tried and failed CPAP and an oral appliance. According to the medical literature Radiofrequency ablation (RFA) can be considered as a treatment in patients with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have been considered and found ineffective or undesirable. Furthermore, the medical literature shows that treatment to the base of the tongue is the most effective in improving the quality of life and reducing obstructive sleep apnea symptoms. Based on the medical literature and clinical documentation provided, radiofrequency ablation of the tongue base is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in otolaryngology with sub-specialty certification in sleep 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 services of an anesthesiologist during a colonoscopy for evaluation of his colonic polyps. The physician reviewer found that the use of monitored anesthesia care services during the colonoscopy was not medically necessary. Per the peer-reviewed medical literature, an alternative to monitored anesthesia care is the administration of propofol by a specially trained nurse or endoscopy assistant, working under the direction of an endoscopist. Given its pharmacologic properties, propofol has been rapidly adopted for gastrointestinal endoscopy for complex procedures and more recently for routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. The use of monitored anesthesia care may be considered necessary for gastrointestinal endoscopy, bronchoscopy, and interventional pain procedures where there is documentation of specific risk factors for significant medical conditions are present. Such increased risks for complications include severe comorbidity, morbid obesity, documented sleep apnea, history of anticipated intolerance to standard sedatives, patients younger than 18 years or 70 years or older, patients with increased risk for airway obstruction due to anatomic variation, and prolonged or therapeutic gastrointestinal endoscopy procedures requiring deep sedation. As the patient does not meet any of the criteria, the use of monitored anesthesia during the patients colonoscopy was not medically necessary. Final Result: The reviewer determined that the services at issue were 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 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.