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

An enrollee has requested authorization and coverage for Humira 40 mg/0.8 ml pen for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the records document a history of rheumatoid arthritis, scleritis and side effects from chronic steroid use.  The most recent visit notes inflammation, although the examination in the records fails to demonstrate this.  It is unclear from the records how much methotrexate the patient is taking.  Per the medical evidence, methotrexate is effective in most patients with moderate to severe rheumatoid arthritis.  For patients using methotrexate, it may take up to three months to see the full effects.  In this patients case, it is unclear what dose the patient is on and how active her disease is.  As such, the medical records fail to demonstrate that the patient has received an adequate trial of methotrexate prior to adding the anti-tumor necrosis factor agent.  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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in rheumatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old enrollee has requested applied behavior analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the current medical evidence supports ABA therapy for children with autism spectrum disorder.  Reichow and colleagues found the benefits of ABA are significant with regards to cognitive, language and adaptive gains.  The study by Orinstein and colleagues found that children with optimal outcome after a diagnosis of autism started ABA earlier and had a higher total number of hours of services.  In this patients case, she has made progress with the majority of the maladaptive behaviors.  She still has some noncompliance and tantrums which require support.  Although the records note improvement, reducing the number of hours of ABA therapy per month of direct and supervisory ABA services, as per the Health Plan's determination would most likely lead to a regression and return of the behaviors that have been already addressed.  In this clinical setting, the medical records support the medical necessity of a portion of the requested services.  Specifically, the provider's request in hours per month of direct ABA therapy, for supervision and for parent training is medically indicated for the treatment of this patient.Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 hip arthroplasty for treatment of the enrollees medical condition. The Health Plan has denied this request indicating that the requested procedure is not medically necessary for treatment of the enrollees medical condition. Findings: The physician reviewer found that the standard practice and the medical literature recommend total hip arthroplasty when all reasonable conservative measures have been exhausted and other reasonable surgical options have been seriously considered or implemented. These criteria include exercise therapy, supervised physical therapy and/or home rehabilitation exercises, and medications (unless contraindicated non-steroidal anti-inflammatory drugs or steroid injection). Subjective findings should include limited range of motion, or night-time joint pain, or no pain relief with conservative care. The American College of Rheumatology 2012 recommended total joint arthroplasty for patients with hip osteoarthritis following failed medical therapy. Medical therapy recommendations included exercise, weight loss for overweight patients, medication management, walking aids, and psychosocial interventions (Hochberg et al). Hofstede and colleagues stated that study results showed that pre-operative function and the severity of radiological osteoarthritis may be strong indicators of effectiveness of total hip arthroplasty. In this patients case, the left hip x-ray documented a normal study and the signals from the visualized osseous structures were unremarkable. Moreover, there is mild loss of left hip range of motion with groin pain in internal and external rotation. While current treatment includes opioid medications, activity modification, and corticosteroid injections, detailed evidence of exercise and physical therapy are lacking. There is also a lack of imaging evidence of hip osteoarthritis or any other hip pathology to support the medical necessity of a total hip replacement. Therefore, evidence based medical guidelines and peer-reviewed literature criteria have not been met, in this patients case. As such, the requested hip arthroplasty is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested stereotactic body radiotherapy (SBRT) for treatment of the enrollees metastatic pancreatic neuroendocrine tumor and breast cancer. Findings: Two physician reviewers found that external beam radiation therapy (EBRT) remains a conventional and efficacious method of palliative radiation therapy for patients with spine metastases. By comparison, SBRT has resulted in comparable rates of pain relief and late treatment related toxicity. SBRT continues to show promise as an emerging modality in selected patients with spine metastases. In the peer-reviewed medical literature, Mahadevan and colleagues concluded that SBRT is feasible and appears to be an effective treatment modality for re-irradiation after conventional palliative radiation fails for spine metastasis patients. This patient has widespread metastatic disease, yet her spine remains untreated. Thus, conventional palliative radiation therapy is considered the standard of care. Given these findings, the requested SBRT is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the combination of carfilzomib and daratumumab infusions for treatment of the enrollees multiple myeloma. Findings: The physician reviewer found that the combinations of carfilzomib and daratumumab infusions are medically necessary for treatment of the patients medical condition. Daratumumab (Darzalex) is a monoclonal antibody directed against CD38. It was approved by the U.S. Food and Drug Administration (FDA) for the treatment of myeloma in patients who have progressed on proteasome inhibitor or immunomodulatory agents. A phase I trial showed that daratumumab with bortezomib/dexamethasone was a safe combination (Moreau, et al). Building on such results, a recent phase III, randomized clinical trial showed that daratumumab/bortezomib/dexamethasone had increased overall response rate and improved progression free survival compared with bortezomib/dexamethasone on its own (Palumbo, et al). Carfilzomib (Kyprolis) is an agent in the same class as bortezomib. Carfilzomib is an irreversible proteasome inhibitor that is approved by the FDA for the treatment of myeloma for patients that have progressed on one or more prior therapies. There is evidence in the medical literature showing responses in patients who have progressed on bortezomib therapy, an agent with a similar mechanism of action. In this case, the patient presents with aggressive myeloma with a need for urgent therapy. As such, the combination of carfilzomib and daratumumab infusions is medically necessary for treatment of the patients aggressive myeloma.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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 re-exploration and repair of the failed subarachnoid shunts by placing a pleural shunt at each cyst location anterolateral at T5-6 and posterior lateral at T7-8 for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient medical evidence to support the requested procedure in this clinical setting. The standard procedure is cysto-subarachnoid shunts but they have a greater tendency to fail since they are a passive conduit for fluid, such as in this patients case. Instead, the recommended pleural shunt utilizes the negative pressure of the pleural cavity to draw fluid from the cyst which provides better long term results for patients. Thus, the recommended pleural shunt is clinically appropriate and effective to relieve spinal pressure and stop the progression of this patients symptoms. All told, the requested re-exploration and repair of the failed subarachnoid shunts by placing a pleural shunt at each cyst location anterolateral at T5-6 and posterior lateral at T7-8 is medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested procedure is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in neurological 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 authorization and coverage for Harvoni 90/400 mg 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 treatment-naive genotype 1a 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Viekira Pak or Harvoni.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. There is a lack of head-to-head direct comparison trials showing that Harvoni is superior to Viekira Pak.  In this patients case, no medical contraindication to Viekira Pak/ribavirin was documented.  Although hepatitis C treatment is needed in this case, Harvoni is not supported over Viekira Pak. The Health Plan has offered Viekira Pak as an alternative. For these reasons, the requested treatment with Harvoni for eight weeks is not medically necessary for the treatment of this patients hepatitis C infection.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 physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Three 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 patients case, there were two indications for breast tomosynthesis.  One is the ability of tomosynthesis to better characterize and localize suspicious calcifications.  The other is the heterogeneously dense nature of her breasts.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.   The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Therefore, digital breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue were 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: All three physician reviewers 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that according to Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of digital breast tomosynthesis over conventional mammogram due to improved cancer detection rate. In sum, digital breast tomosynthesis used to perform the breast examination was likely to have been more effective than other methods of evaluating this patient for breast cancer.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers 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 has requested Harvoni for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per guidelines, treatment-naive, genotype 1 patients should be treated with Harvoni.  Non-cirrhotic patients with a viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks.  The guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Harvoni for eight weeks is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement digital breast for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). In this clinical setting tomosynthesis is indicated to assess borders, as it separates out the overlap and positioning and localizes structures in one view. The addition of tomosynthesis allows the decrease in the number of images needed, often eliminating the need for cone compression, magnification and rolled images, and saves time and radiation dose. All told, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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: All three physician reviewers 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.