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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Epclusa 400 mg-100 mg for the treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that the current medical evidence supports the requested medication regimen in this clinical setting.  According to 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 life expectancy less than 12 months due to non-liver-related conditions.  This applies regardless of fibrosis stage.  Per the guidelines, Epclusa is recommended as first-line for treatment-naive genotype 2 patients. Delay in treatment may result in decreased survival.  All told, Epclusa 400 mg-100 mg is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen 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 Jakafi (ruxolitinib)  for treatment of the enrollees graft versus host disease (GVHD). Findings: The physician reviewer found that the requested Jakafi is medically necessary for treatment of the patients medical condition. According to Spoerl and colleagues GVHD is a severe complication of allogeneic hematopoietic cell transplantation (allo-HCT) characterized by the production of high levels of proinflammatory cytokines. Activated Janus kinases (JAKs) are required for T-effector cell responses in different inflammatory diseases, and their blockade could potently reduce acute GVHD. The authors treated six patients with steroid-refractory GVHD with ruxolitinib and concluded that ruxolitinib represents a novel targeted approach in GVHD by suppression of proinflammatory signaling that mediates tissue damage and by promotion of tolerogenic Treg cells. In this case, the patient underwent allogeneic hematopoietic stem cell transplant and developed GVHD. Immunosuppressive therapy is indicated for this patient. There is sufficient medical evidence supporting ruxolitinib has a role in treating patients who have exhausted standard treatment options such as in this case. All told, Jakafi is medically necessary for treatment of the patients GHVD.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 medical oncology and hematology 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 Repatha 140 mg/ml Sureclick for treatment of the enrollees hypercholesterolemia. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  Based on the records provided, the patient has known coronary disease, documented severe intolerance to several statin medications, and a very high low-density lipoprotein level despite maximal tolerated statin dose.  Repatha is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of low-density lipoprotein cholesterol.  This patient fits into the latter category.  There is sufficient documentation to indicate the patient is unable to tolerate additional statin medication and that his low-density lipoprotein remains elevated.  Repatha has been demonstrated to improve cardiac outcome in this patient population.  All told, Repatha 140 mg/ml Sureclick 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 cardiovascular disease 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

An enrollee has requested reimbursement for three-dimensional mammogram.  Findings:  The physician reviewer found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breast density was described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, three-dimensional mammogram performed was likely to have been more efficacious than other modalities for evaluating this patient. Final Result: The reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers are board certified in diagnostic radiology and 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 Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These 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 (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 90/400 mg for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: A female enrollee has requested retroactive authorization and coverage for testing for tumor necrosis factor antagonists and antibodies for evaluation of Crohn's disease. Findings: Three physician reviewers found that in this case, Anser ADA was ordered to direct the management of the patients Crohns disease.  The use of Anser ADA has not been clinically proven to improve patient clinical outcomes, and has not definitively demonstrated clinical utility.  The effectiveness of Anser ADA testing compared with conventional courses of action remains unproven.  Patients being treated with Humira may experience loss of response, but the appropriate method for determination of the cause for loss of response is not clear.  The published studies on the use of anti-adalimumab antibodies and serum levels are retrospective and/or observational in nature.  These small studies demonstrated, at best, correlations between treatment failure and the presence of anti-adalimumab antibodies, which do not allow firm conclusions regarding cause and effect.  Prospective controlled trials providing evidence for the effectiveness of anti-adalimumab antibody testing and serum level testing as part of a clinical management strategy are lacking.  Therefore, the clinical literature does not support the superior effectiveness of testing for tumor necrosis factor antagonists and antibodies over other methods of evaluation. All three reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: The parent of an enrollee has requested air ambulance transport services for treatment of the enrollee, who sustained a traumatic brain injury. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had multiple significant and life-threatening injuries as a result of a motor vehicle accident.  She was hospitalized in the pediatric intensive care unit for over two weeks before she was deemed stable to transfer to an appropriate rehabilitation facility.  Rehabilitation requires the active participation of the family to have its greatest benefit. While the patient may receive several hours of therapy daily, the family is integral in continuing interventions throughout the rest of the day, in addition to providing emotional and even physical support to the patient.  This is particularly true for children because of their developmental needs.  In this patients case, her family resides in Northern California.  The accident occurred while they were on vacation in Southern California.  While it was appropriate to treat this patients acute injuries in the closest trauma center, as she transitions to rehabilitation and long-term recovery, it is essential that she be in an institution where her family can be active participants in her therapy. Family members are considered to play an integral role in the patients recovery and rehabilitation success. Transfer from Southern California to Northern California is prohibitive via land because of the distance, duration, and risk to the patient.  All told, air ambulance transport 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 pediatrics with sub-specialty certification in pediatric critical care 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested retroactive authorization and coverage for continued residential mental health treatment for treatment of the enrollees behavioral health conditions. Findings: The physician reviewer found that there is sufficient support for the services at issue in this clinical setting.  The services at issue were medically necessary in order to stabilize the patient and solidify the gains that she made in residential treatment.  The notes from her family and her psychiatrist indicate that the patient had chronic problems with anxiety.  She has received mental health treatment at various levels of care the previous year, and had become treatment-resistant.  She was still very anxious during the treatment period in dispute and did not feel confident that she could cope outside of the residential structure.  In addition, therapy notes indicate that the family also was worried that she had not yet gained enough coping skills to avoid regression if discharged at that time.  She needed to have the appropriate coping skills and self-confidence to prevent a relapse.  It appears that she did make these improvements during the treatment dates in dispute.  All told, residential mental health treatment was 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 with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested right breast capsulectomy with cadaveric skin for treatment of the enrollees right breast firmness status post bilateral breast capsulectomy and breast implant replacement.  Findings: The physician reviewer found that there is insufficient documentation that the patients initial surgery was done for reconstructive reasons. She now has evidence of a possible painful right breast capsular contracture. The functional compromise is related to the painful contracture on the right. In addition, she had had a previous complication related to implant rupture which was treated. Augmentation mammaplasty is a common cosmetic procedure. As noted in the peer-reviewed medical literature, complications that arise from this surgery are well documented to include implant rupture and capsular contracture. Handel and colleagues noted that it has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation. Marquis and colleagues reported that capsular contracture is the most common and severe complication associated with silicone breast implants. There is evidence that this patient may have a functional deficit related to her implants, including a possible painful capsular contracture, which could be resolved with implant removal. Further, the medical documentation provided does not define a severe capsular contracture and the most effective treatment would be implant removal. As the initial implants were placed for cosmetic concerns, the requested surgery for capsulectomy with cadaveric skin is cosmetic treatment and not medically necessary.Final Result: The reviewer determined that the requested surgery 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 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 reimbursement for ground and air ambulance transport.Findings:  The physician reviewer found that there is a lack of clinical support for the services at issue in this patients case. Per the submitted documentation, the patient was transferred from Torrance, California to Atlanta, Georgia to be near family members.  However, there are long term care facilities within the Los Angeles, California vicinity which could have accommodated the patients transfer from the hospital. The patients transfer to Atlanta, Georgia was due to personal preference. The medical services and the medical care this patient required were available to him within the Los Angeles area. The documentation submitted do not support the ground and air ambulance transportation from California to Georgia. Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in in internal medicine with sub-specialty certification in pulmonary disease 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 reimbursement for digital breast tomosynthesis for an annual breast screening examination. Findings:  The 3 physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts. In this particular patient, there are two separate indications for tomosynthesis. First, she has breasts that have been described as being dense.  It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Second, the mass that was discovered in the subareolar area of her right breast can be better evaluated with the addition of tomosynthesis.  Therefore, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 reviewers determined that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Remicade for treatment of the enrollees neurosarcoidosis.  Findings: Two physician reviewers found that the medical literature supports the efficacy of infliximab for treatment of neurosarcoidosis when steroids have been unsuccessful. In this patients case, the patient has not responded to high dose of steroids. According to the treating provider, the patient has been on chronic steroids with insufficient improvement. There is clinical support of Remicade as an alternative therapy for treatment of neurosarcoidosis when other treatment options have not provided improvement. All told, the requested Remicade is likely to be more efficacious than the available standard therapy for treatment of this patient.Final Result: Two of three reviewers determined that the requested medication is 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: All three physician reviewers are board certified in neurology 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.