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 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.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested Harvoni 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 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 Viekira Pak and ribavirin for treatment of her 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 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks. This recommendation is based on multiple high-quality clinical trials.  For these reasons, the requested treatment with Viekira Pak and ribavirin 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.  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 a combination of Sovaldi and Daklinza for 12 weeks for the treatment of his 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.  Per the guidelines, patients with prior liver transplant are highest priority for treatment of hepatitis C.  For treatment-experienced ribavirin-ineligible genotype 3 patients with liver transplant, the guidelines recommend daily Daklinza and Sovaldi for 24 weeks.  The requested treatment duration of 12 weeks is not consistent with the guidelines. As such, the requested treatment with Sovaldi and Daklinza for 12 weeks is not medically necessary. Final Result: The reviewer determined that the requested medications are 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 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 bilateral balloon frontal sinuplasty for the treatment of his medical condition.   Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Endoscopic sinus surgery has been widely used since the early 1980s.  Since that time, instrumentation has evolved, including the use of microdebriders and computerized localization.  The use of balloon instrumentation is the addition of another mode of carrying out standard functional endoscopic sinus surgery in a less invasive fashion.  Per the medical literature, the use of balloon instrumentation shows positive outcomes in symptomatology and sinus ostia patency.  In addition, balloon sinuplasty has been shown to require less postoperative debridement than standard endoscopic sinus surgery.  All told, bilateral balloon frontal sinuplasty was likely to have been superior over other treatment options.   Final Result: Two reviewers determined that the services at issue were 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 otolaryngology 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:  The parent of an enrollee has requested water circulating cold pad with pump for treatment of the enrollees medical condition.   Findings:  Two physician reviewers found that the water circulating cold pad with pump at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The standard of care post-operatively following a knee arthroscopy is the use of icepacks. There is a lack of sufficient support demonstrating cryotherapy results in increased efficacy when administered through a mechanized pump versus icepacks and ice bags. The study by researchers evaluated the use of cryotherapy following anterior cruciate ligament reconstruction. Six studies were reviewed, and some individual studies reported significant benefit. However, the pooled analysis did not support a significant impact compared to traditional methods of delivering cold, such as with icepacks. Although the literature review by researchers provides support for reduction in pain levels at 48 hours after surgery, there is a lack of sufficient evidence for efficacy of cryotherapy for other outcomes such as analgesic medication use, range of motion, blood loss, hospital stay or quality of life. Moreover, the authors concluded that there was a need for additional studies with randomized trials before the ambiguity as to the efficacy of cryotherapy can be resolved. In sum, the use of water circulating cold pad with pump was not likely to be more beneficial for treatment of the patients medical condition compared to other modalities. Final Result: Two reviewers determined that the services at issue were 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:  One reviewer is board certified in orthopedic surgery and is actively practicing. Two reviewers are board certified in physical medicine and rehabilitation 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 has requested a wearable cardiac defibrillator for treatment of his medical condition.    Findings:  Three physician reviewers found that based on the records provided, the patient presented with symptoms of congestive heart failure. In this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time of more than 90 days where continued left ventricular dysfunction is documented to persist in spite of appropriate treatment.  A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve outcome. Studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. At this time, prophylactic wearable external defibrillator would be indicated only if accepted criteria for an implantable defibrillator were met and an implantable defibrillator could not be placed, needed to be significantly delayed (due to infection, for example) or required explanation. Therefore, the wearable defibrillator in this circumstance has not yet been demonstrated by existing scientific literature to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 a wheelchair and related equipment for treatment of her medical condition.   The physician reviewer found that the requested services are not medically necessary for treatment of the patients medical condition.  According to the documentation submitted for review, the patient relies on a wheelchair for mobility and has requested a new wheelchair. However, the patient has not had an evaluation in the past year. An updated evaluation is indicated to support the need for a new wheelchair. In addition, the evaluation helps to determine the type of wheelchair that will suit the patient best. Given the lack of a recent evaluation with an updated history, physical examination, and functional status, the medical necessity for the requested services has not been established in this clinical setting. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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  immunoadsorption therapy for treatment of his medical condition. The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  The medical records document coronary vasospasm, a possible autoimmune mechanism and ongoing chest pain reported to be refractory to medication.  One note reported only minimally abnormal autoantibodies to usual receptors mediating vasospasm.  Additionally, the description of ongoing chest discomfort is atypical for angina since it is worse with standing and worse with arm movement.  There is a lack of evidence in the scientific literature supporting the efficacy of immunoadsorption treatment for the diagnosis of coronary vasospasm.  In summary, it is not certain that autoantibodies are the cause of the patients cardiac condition based on the documentation provided, his current symptoms as documented are not clearly anginal, and the efficacy of treatment with immunoadsorption therapy is not proven.  Therefore, the requested immunoadsorption therapy is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in 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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a permanent subcutaneous defibrillator (S-ICD) for treatment of his medical condition.   Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  In this patient's circumstance, an implantable defibrillator is reasonable and considered standard accepted practice in the medical community.  Placement of a subcutaneous defibrillator has potential long-term advantages in this patients case.  For this young patient who will likely require a defibrillator for many decades, the risk of lead failure and lead extraction, which are associated with significant morbidity and mortality, are higher when implanted with a traditional endocardial lead device.  Subcutaneous leads are not subject to the stresses of the cardiac contraction and so should be less likely to fail or need replacement.  Also, if lead failure were to occur then the subcutaneous lead should be easier to access and extract with lower risk of morbidity.  Furthermore, the patient's cardiac condition does not predispose to symptomatic bradycardia that may require backup pacing only provided by a standard endocardial defibrillator lead.  Therefore, given the long-term advantages of a subcutaneous defibrillator in this patient and the unlikely need for therapies provided only by an endocardial lead system, the requested permanent subcutaneous defibrillator is likely to be superior over other treatment options.   Final Result: Two reviewers determined that the requested services are 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 internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her 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.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials.  For these reasons, the requested treatment with Harvoni 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 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 24 weeks for treatment of her hepatitis C virus (HCV).  Findings:  The physician reviewer found that Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. In this case, the patients presents with a diagnosis of HCV genotype 1a with a high viral load without advanced fibrosis. According to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). However, guidelines recommend daily Harvoni for 12 weeks for patients with HCV genotype 1 infection. Thus, a 24-week course of Harvoni is not AASLD/IDSA recommended in this patients clinical setting. For the reasons provided, the request for Harvoni for 24 weeks is not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of his hepatitis C virus. 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. This applies regardless of fibrosis stage or viral load. Per guidelines, 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. Per AASLD guidelines, renal impairment does not require modification of therapy if creatinine clearance is over 30 mL/min.  AASLD guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested residential treatment for treatment of her behavioral health condition. Findings:  The physician reviewer found that the requested residential treatment was medically necessary for treatment of the patients medical condition.  Based on the documentation provided, the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  Further, in reviewing the clinical documentation, the residential treatment provided thereafter was safe, appropriate and consistent with good medical practice. The duration of services for a case of this complexity was consistent with community standards. Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness. Accordingly, the services at issue were medically necessary for treatment of the patients behavioral health condition.   Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.