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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his medical condition.  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 define acute hepatitis C as presenting within six months of the exposure with new rise in alanine aminotransferase (ALT) without alternative cause or low or fluctuating hepatitis C RNA values. In this clinical setting, the guidelines also state that the provider and patient may elect to treat or to delay treatment initiation. In this case, the patients provider has elected to initiate treatment with Harvoni for 12 weeks. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic Hepatitis C Genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of the 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 36 hours per week of ABA therapy, 14 hours per month of supervision and two hours per month of parent training for treatment of the enrollees autism spectrum disorder. Findings: Two physician reviewers found that the submitted documentation supports the medical necessity of the requested services.  The medical evidence has demonstrated that early and intensive ABA services provide benefits for children with autism spectrum disorder.  Based on the medical records, this patient has been progressing with 36 hours of ABA per week.  The core components of an effective program include parent training hours, and intensive direct intervention in the home, community and other settings.  In this patients case, 36 hours per week of ABA therapy, 14 hours per month of supervision and two hours per month of parent training are medically indicated for the treatment of this patient. Final Result: Two reviewers 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: One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. Two reviewers are board certified in neurology with special qualification in child neurology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested foam sclerotherapy for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has a history of pain and other symptoms consistent with right leg venous insufficiency. The records indicate that the patient has completed conservative therapy and her symptoms justify treatment. The patient has had prior foam sclerotherapy of her right leg but has now had increasing symptoms. The requested procedure is likely to be more efficacious than any available standard therapies. The patient demonstrated symptoms interfering with activities of daily living and her anatomy indicates that she is amenable to foam treatment. Treatment with ultrasound-guided foam sclerosant in this clinical situation is supported by peer-reviewed studies and will likely improve the patients symptoms including pain and functional impairment. For these reasons, the requested foam sclerotherapy is likely to be more beneficial than any standard therapy for treatment of this patients varicose veins.  Final Result: Two reviewers determined that the requested procedure 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 reviewers are board certified in surgery with sub-specialty certification in vascular surgery 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Three physician reviewers found that the medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with dense tissue.  This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, it is likely the addition of breast tomosynthesis to the usual two protocol was more beneficial to the patient than had the examination been done with two-dimensional technique alone.  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.  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:   The parent of an enrollee has requested Saizen growth hormone for treatment of the enrollees short stature.  Findings:  The physician reviewer found that the records document that this patients height is more than two standard deviations below the mean for age and gender. In addition, his height velocity off growth hormone therapy is poor and his bone age is delayed. According to the Pediatric Endocrinology Society guidelines, a trial of growth hormone therapy should be approved for children with otherwise unexplained short stature who pass growth hormone stimulation tests but who meet most of the following criteria: (1) height more than 2.25 standard deviations below the mean for age or more than two standard deviations below the mid-parental height percentile; (2) growth velocity less than the 25th percentile for bone age; (3) bone age more than two standard deviations below the mean for age; (4) low serum IGF-1 and/or IGFBP-3; and/or (5) other clinical features suggestive of growth hormone deficiency. This patient meets most of these criteria. Accordingly, the requested Saizen growth hormone is supported as medically necessary for treatment of this patients short stature.  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 pediatrics with sub-specialty certification in pediatric endocrinology 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  The technique often allows the reader to separate dense glandular elements from underlying mass/architectural disorder, resulting in a decrease in callbacks, decrease in biopsies and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis was likely of greater benefit to the patient than had her study been done with two-dimensional technique alone.  In sum, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that tomosynthesis has proven to be a very useful screening tool to screen for breast cancer. However, once an abnormality has been found and the work-up of mammography and ultrasound follows, the addition of tomosynthesis does not add appreciable value. The spot magnification views and the ultrasound will provide enough information for recommendation and management. Thus, the addition of tomosynthesis did not add to the conventional views. Therefore, the use of breast tomosynthesis was not 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 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 diagnostic radiology 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 Sovaldi and Daklinza for treatment of her hepatitis C virus genotype 2.  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 only recommend one therapy for ribavirin-ineligible genotype 2 patients who have failed peg-interferon with ribavirin, which is Sovaldi and Daklinza. This recommendation is based on two clinical trials (Wyles, et al; Sulkowski, et al). Further, the AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). This patient is ineligible for alternatives containing interferon or ribavirin due to prior severe adverse reactions, and a pre-existing medical condition.   For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.  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.Qualifications/Credentials: 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this 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.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This technique often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, increase in detection of small cancers and decrease in callbacks.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the exam been done using two-dimensional imaging alone.  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 reviewers are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested OxyContin for the treatment of his medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  This patient has chronic nonmalignant pain.  The current standard of care for chronic pain in this setting is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy.  If there is poor response to conservative therapy, then surgery should be considered.  High-dose opioids are associated with a high-risk of dependence and tolerance and are not recommended.  All told, OxyContin was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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 Belbuca for treatment of her medical condition.  Findings: The physician reviewer found that the request for Belbuca was not and is not medically necessary for treatment of the patients medical condition. Based on the documentation submitted for review, not all non-opioid treatment options have been utilized or optimized. In addition, there is no mention the patient has trialed behavior therapy given the support for its use (Lee, et al).  For these reasons, the requested for Belbuca was not and is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the medication at issue was not and 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given the support cited above, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 reviewers are board certified in diagnostic radiology 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 a replacement battery for her spinal neuro-stimulator and a pain pump to regulate morphine dose for treatment of her post lumbar spine surgery syndrome and lower extremity compartment syndrome. Findings:  The physician reviewer found that the spinal cord stimulator is clinically supported for treatment of the patients medical condition. The patient indicated that the device has provided pain relief but that currently the battery needs replacement. A randomized controlled study by Deer and colleagues supports the efficacy of spinal cord stimulation (SCS) in treating failed back surgery syndrome and complex regional pain syndrome. Taylor and colleagues note that spinal cord stimulation was effective in reducing pain irrespective of the location of the chronic pain. This review also supports SCS as an effective pain relieving treatment for chronic low back pain with predominant leg pain with or without a prior history of back surgery. As such, the requested replacement battery for the patients spinal neuro-stimulator is medically necessary for treatment of the patients medical condition. On the other hand, the requested intrathecal pump or the pain pump is not clinically supported in this case. The medical records do not indicate findings of spasticity for which the device may be indicated nor do the records show a terminal condition for which palliative care is needed.  Moreover, the documentation shows no indication of intolerance or failure of oral opioids being taken for the noted pain condition to support the need to deliver such medications intrathecally. A paper by Hayek and colleagues notes a lack of controlled studies showing benefit of intrathecal opioids for non-cancer pain.  Such use may be considered in patients with demonstrated failure of or intolerance to oral administered opioids. Thus, the request for a replacement battery is medically necessary for treatment of the patients medical condition but the request for a pain pump is not medically necessary.  Final Result: The reviewer determined that the requested replacement battery is medically necessary for treatment of the patients medical condition but the request for a pain pump is not medically necessary. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in neurology with sub-certification 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.