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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Mepron for treatment of her medical condition. Findings:  The physician reviewer found that the patient does not meet criteria for acute Babesia infection. Her symptoms are non-specific. The patients symptoms may not be related to Babesia infection. Babesia duncani is not known to cause clinical disease. The peer reviewed literature does not support a state of chronic infection with Babesia. She has already had multiple courses of antibiotics without resolution of problem. Thus, the patient will not likely benefit from another course of Mepron for the treatment of Babesia infection. As such, the medication at issue was not and is not medically necessary to treat 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 reviewer is board certified in internal 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:  An enrollee has requested growth hormone (GH) therapy with Genotropin for treatment of her medical condition.   Findings:  The physician reviewer found that growth hormone deficiency is a medical condition in which the body does not produce enough GH. Recognized effects include reduced muscle mass and strength, reduced bone strength and osteoporosis, decreased energy levels, impaired concentration and loss of memory, increased body fat, lipid abnormalities, and insulin resistance. GH replacement therapy can provide a number of measurable benefits to GH-deficient adults. These include improved bone density, increased muscle mass, decrease of adipose tissue, faster hair and nail growth, strengthened immune system, increased circulatory system, and improved blood lipid levels. In this case, based on the clinical documentation submitted, the patient will likely benefit from growth hormone replacement therapy. As such, growth hormone replacement therapy with Genotropin is medically necessary in this clinical setting. 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-certification in endocrinology and metabolism 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 for treatment of his chronic hepatitis C virus (HCV). Findings:  The physician reviewer found thatthe American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state the following: `Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. According to the guidelines, treatment is necessary to avoid untoward complications from advanced disease, including liver failure, hepatocellular carcinoma and extrahepatic complications from hepatitis C virus. The peer-reviewed evidence suggests that treatment delays may decrease the benefit of sustained viral response. In a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier in which case the long-term survival was better. In addition, the guidelines state that high priority for treatment owing to high risk for complications include patients with fibrosis (Metavir F2). Based on this patient's Metavir score, treatment should not be delayed. Viekira Pak has shown 99% efficacy in achieving cure for treatment-naive chronic hepatitis C virus patients with genotype 1. As such, the requested Viekira Pak is clinically appropriate and medically necessary for treatment of the patients hepatitis C virus. 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 hepatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested emergency room services on an emergent or urgent basis. Findings:  The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with severe pain that persisted, awakened her from sleep, and was exacerbated by breathing. A prudent person would have been concerned for the possibility of serious medical illness as an etiology. The pain was consistent with pulmonary embolism, thoracic aortic dissection, kidney stone, spontaneous pneumothorax, and multiple other etiologies.  Any of these conditions could have put the patients life in immediate jeopardy and may have caused serious impairment to bodily functions. In sum, the patient was suffering from symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in causing serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided did meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency services.  Credentials/Qualifications: The reviewer is board certified in emergency 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 acute inpatient psychiatric hospitalization services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was not in withdrawals.  She was medically stable. She was not psychotic.  She had no delusions or hallucinations in any modality.  Per the medical records, the patient was not homicidal, violent or aggressive towards others.  She did not require 24-hour medical and nursing supervision on an inpatient level of care.  Thus, acute inpatient psychiatric hospitalization services was not medically indicated for the treatment of this patient.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings:  The physician reviewer found that review of the submitted evidence demonstrates the requested Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the American Association for the Study of Liver Diseases/Infectious Disease Society of America (AASLD/IDSA) guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. The evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. The goal of treatment of HCV-infected persons is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure. The providers recommendation of Harvoni is consistent with FDA guidelines and is medically indicated to prevent further development and progression of fibrosis due to ongoing HCV infection. All such, the requested Harvoni  is medically necessary for treatment of the patients hepatitis C virus. 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 his hepatitis C virus.  Findings:  The physician reviewer found that according to 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 drug is FDA-indicated for the treatment of chronic hepatitis C genotype 1 infection in adults. In addition, Harvoni carries the highest AASLD/IDSA recommendation for treatment of HCV patients with this patients characteristics. While the use of Harvoni is appropriate for this patient, the proposed treatment duration of 24 weeks exceeds AASLD/IDSA guideline recommendations in this setting. Further, per the literature, in patients with viral loads less than 6 million IU/mL `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.`  Thus, although the patient is an appropriate candidate for treatment with Harvoni, the requested duration of 24 weeks exceeds current AASLD/IDSA guideline and prescribing recommendations for patients such as this patient with genotype 1 infection. As such, the request for Harvoni for 24 weeks is not medically necessary for this patient. 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 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:   An enrollee has requested ceftriaxone sodium injections for treatment of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the requested services in this clinical setting.  Late Lyme disease is typically associated with intermittent or persistent arthritis involving one or a few large joints, and/or certain rare neurologic problems, primarily a subtle encephalopathy or polyneuropathy.  Arthritis may be the presenting manifestation of the disease.  The recommended initial treatment regimen is oral doxycycline or oral amoxicillin.  Approximately 90 percent of patients with arthritis respond to a single course of oral therapy.  In patients whose arthritis has improved, but not completely resolved, after one month of oral therapy, a second course of the same antibiotic is suggested.  In contrast, patients who have had little or no improvement after the initial course should be treated with intravenous therapy.  In this case, the documentation does not support that the patient has failed first-line therapy with an oral antibiotic. The documentation does not support that the patient had any neurologic or cardiac involvement.  Therefore, the requested ceftriaxone sodium injections are not likely to be of greater benefit than other treatment options.  Final Result:  Three 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:   One reviewer is board certified in internal medicine with sub-specialty certification in infectious disease and is actively practicing.   Two reviewers are board certified in internal medicine 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 radiofrequency ablation of a cancerous lesion of the left lobe of the liver for treatment of his medical condition.  Findings:  Three physician reviewers found that treatment for metastatic neuroendocrine tumors is considered palliative.  Treatments have been designed to decrease tumor burden and subsequent symptoms.  Progression-free survival and overall survival has been improved with treatment, especially in those with liver only disease.  Surgery is a first-line therapy.  However, management of the liver metastases can vary depending on location, size, liver function, and extrahepatic tumor burden.  Treatment decisions are often made in the multidisciplinary forums to review films and discuss options.  With progressive disease, the decision was made to proceed with ablation.  This is reasonable as it preserves as much liver function as possible while effectively treating the growing lesions.  There is sufficient support for the requested services in this clinical setting.  All told, the requested services are likely to be of greater benefit than other treatment options.  Final Result: Three 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested mental health intensive outpatient program services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that this patient has substantial academic and social dysfunction.  It is unlikely that an ongoing individual therapy at this time will show marked improvement in these areas without the containment of a more enhanced program.  Therefore, mental health intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

 Nature of Statutory Criteria/Case Summary: An enrollee has requested osteochondral allograft transplantation (transplant cartilage cells to his patella bone) for treatment of his medical condition.  Findings:  Three physician reviewers found that evidence-based medical guidelines and peer-reviewed literature support the use of osteochondral allograft transplantation as a primary or salvage procedure for large chondral or osteochondral defects.  Generally, the literature has supported the use of osteochondral allograft in the weight-bearing portions of the medial or lateral femoral condyle.  However, current long-term evidence exists for the use of osteochondral allograft in the patella. There is peer-reviewed evidence to support the use of cartilage repair as a primary procedure versus microfracture.  Given the age of this patient, functional loss, failure of conservative treatment, and the imaging findings of a large osteochondral lesion, the requested services are likely to be of greater benefit than other treatment options. Final Result: Three 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 orthopedic 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:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  The advantage of breast tomosynthesis relates to its ability to separate out normal glandular elements of the breast from underlying mass/architectural distortion, thereby resulting in a decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the two-dimensional imaging protocol of digital mammography was likely of greater benefit to the patient than had her examination been done with 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested food allergy testing (IgG food sensitivity test) for treatment of the enrollees fatigue.   Findings:  Three physician reviewers found that the testing at issue is not supported by the peer-reviewed literature. IgG testing for food allergies is not supported by national guidelines. Currently, elevated IgG levels for particular food allergens are thought to reflect prolonged exposure to components of that food, rather than a sensitivity to that food.  While research in this area is ongoing, and may be found to be useful for some indications in future, at this time IgG testing has not been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the testing at issue was 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: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in pediatrics with sub-specialty certification in pediatric gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.