Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensity modulated radiation therapy for treatment of his medical condition.   Findings:  Three physician reviewers found that the patients history supports the use of intensity modulated radiation therapy.  Long-term complications from Hodgkins disease survivors include cardiac and pulmonary toxicity from radiation therapy.  Newer techniques, such as intensity modulated radiation therapy, can reduce the radiation dose to the lungs and heart, especially in patients with large anterior mediastinal masses.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested intensity modulated radiation therapy is likely to be superior over 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 radiation oncology 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 fentanyl transdermal patch for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. The patient presents with chronic pain and use of long term narcotics.  Pain management notes document that the patient has been on opiates for a very long period of time and is no longer deemed a candidate for chronic opiate therapy. In addition, the medical records document that the patient is not a candidate for fentanyl. The Health Plans recommendation for the patient to return to pain management group to discuss a multimodal approach to pain management is medically appropriate in this clinical setting.  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 anesthesiology with sub-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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted records demonstrate the medical necessity of a portion of the services at issue.  Although the patient was said to be easily frustrated, there were no episodes of emotional outbursts/lability described.  Initially, she was reported to be inattentive, impulsive, and hyperactive.  She was cooperative with staff.  She participated in her treatment and in groups.  She was doing better in school.  She subsequently began developing insight and started to recognize behavior patterns she engaged in with her parents.  She was learning to calm herself and practice emotional regulation with different responses.  All told, the medical records demonstrate the medical necessity of residential treatment center services initially, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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 genetic testing (MyRisk) for evaluation of her medical condition.   Findings:  Two physician reviewers found that BRCA1 mutation can increase risk for breast, ovarian, cervical, uterine, pancreatic, gastric, and prostate cancers.  BRCA2 mutations can increase risk for breast, ovarian, gallbladder, bile duct, prostate, pancreatic, and gastric cancers.  In the event the BRCA tests were negative, there is still a possibility of hereditary predisposition from another gene defect.  There are guidelines in place that evaluate the occurrence of Lynch syndrome or hereditary nonpolyposis colorectal cancer (HNPCC) tumors in families.  The most common extracolonic cancer in Lynch syndrome is endometrial cancer followed, in no particular order, by ovarian, gastric, renal, small intestine, pancreas, hepatobiliary, and ureteral.  In this patients case, the MyRisk panel was appropriate since the current clinical situation may be caused by several potential cancer-causing genes.  In sum, genetic testing (MyRisk) was likely to have been superior over other options.   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 internal medicine with sub-specialty certification in medical oncology 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 indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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:   The parent of an enrollee has requested Adderall XR for treatment of the enrollees attention deficit/hyperactivity disorder.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  In this patients case, the documentation does not include sufficient details regarding prior trials of alternative medications.  The records do not document how these medications were less effective.  Additionally, other medication trials were not described.  The clinical documentation fails to establish the necessity of Adderall XR in this patients case.  All told, Adderall XR is not medically indicated for the treatment of 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Orthovisc bilateral knee injections and ongoing Orthovisc injections (series of four) for treatment of his medical condition.    Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  In the setting of osteoarthritis of the knee, viscosupplementation does not lead to clinically meaningful improvement.  Published clinical trials comparing injections of viscosupplementation with placebo have yielded inconsistent results.  Higher quality and larger trials have generally found lower levels of clinical improvement in patients and function than small and poor quality trials.  In sum, the services at issue were not and are not likely to have been more effective than other treatment options.  Final Result: Two reviewers determined that the services at issue were not and 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 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: 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.  The guidelines report that patients with cirrhosis are highest priority for therapy.  Per the guidelines, genotype 1 patients with decompensated cirrhosis who have failed Sovaldi-based therapy should be treated with Harvoni and a low initial dose of ribavirin for 24 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of Harvoni after Sovaldi failure. For these reasons, 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: 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.  Per the medical literature, this technique may result in a decrease in callbacks and increase in detection of small cancers.  There is sufficient support for breast tomosynthesis in this patients case.  In sum, the addition of breast tomosynthesis to the two-dimensional protocol was likely of more benefit to the patient than had the exam 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested partial hospitalization program services for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a threat to herself or others.  Her eating disorder behaviors had decreased.   Her body mass index was increasing.  She was medically and psychiatrically stable.  No new problems emerged.  There was no evidence that stepping her down to intensive outpatient program level of care would lead to decompensation.  Her parents were supportive.  She continued to be preoccupied with body image and perseverative thoughts.  However, these issues did not require partial hospitalization program level of care.  All told, partial hospitalization program services at issue were 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested occipital nerve stimulation for treatment of her medical condition.  Findings:  Two physician reviewers found that this patient has been treated with multiple prophylactic medications which are reasonably expected to offer efficacy in reducing headache frequency and severity.  There are controlled studies demonstrating efficacy of occipital nerve stimulation in the clinical situation of chronic migraine or chronic daily headache.  Per the clinical documentation, occipital nerve stimulation is more likely to offer a meaningful clinical response compared to any other existing standard treatment.   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 neurology and are actively practicing. Al 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 his hepatitis C virus (HCV).   Findings:  The physician reviewer found that current medical evidence supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to nonliver-related comorbid conditions. The recommendation is again to not deny patients treatment if they have early stage disease: this in fact is an indication to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  The medical evidence supports the requested medication in this clinical setting. In sum, the requested medication of Harvoni is medically indicated for this patient.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification 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 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 (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 nonliver-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 (Kowdley, et al; Afdhal, et al).  Per the records, the patient is ineligible for the alternative treatment for genotype 1a, Viekira Pak with ribavirin, due to a pre-existing medical condition. Studies show that this pre-existing medical condition can be exacerbated by ribavirin. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). 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 a cesarean section for treatment of her medical condition. Findings:  The physician reviewer found that cesarean delivery on maternal request typically refers to a primary cesarean delivery performed because the patient requests this method of delivery in the absence of standard medical/obstetrical indications for avoiding vaginal birth.  In this setting, providers are encouraged to examine whether there are practice-based or facility-based changes that can remove some of the concerns that may contribute to a preference for planned cesarean delivery.  Providers should ensure adequate pain management, effective and supportive communication, and a strong commitment to training in low-intervention births.  Performing cesarean delivery on maternal request should be limited to cases in which the provider judges that it is sufficiently safe, given the specifics of the womans pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.  A womans right to be actively involved in choosing the route of her delivery is now widely accepted by clinicians and patients.  In a well-informed patient, performing a cesarean delivery on maternal request is considered medically appropriate.  All told, the requested cesarean section is medically indicated in this clinical setting.   Final Result: The reviewer 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: The reviewer is board certified in obstetrics and gynecology 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.