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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cosentyx for treatment of the enrollees medical condition. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient previously has been treated with topical steroids, retinoids, and antifungal medications without improvement.  The records do not document treatment with a systemic agent. The Health Plan requires failure of both Humira and Stelara prior to treatment with Cosentyx, and this requirement is medically appropriate.  The patient has not met this requirement, as she has not been treated with Humira or Stelara.  The records do not document contraindication to the use of the preferred formulary medications for psoriasis.  All told, the requested medication Cosentyx 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done using two-dimensional imaging 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. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has consultation for gastric bypass surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services in this patients case.  The records do not indicate a known technical or anatomic problem with the gastric bypass which would result in weight regain and or be amenable to surgical repair/improvement.  There is a lack of documented follow-up notes and no updated psychological or dietary evaluation to support the requested services.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested consultation for gastric bypass surgery 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 surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radiofrequency ablation (RFA) for treatment of the enrollees uterine fibroids.  Findings: Two physician reviewers found that as noted in the American College of Obstetricians and Gynecologists (ACOG), there are a number of non-surgical and surgical treatments for heavy periods and fibroids, including non-steroidal anti-inflammatory drugs (NSAIDs), progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion. The ACOG practice bulletin does not include RFA as a treatment option. The RFA device is now approved by the U.S. Food and Drug Administration (FDA) and currently studies are underway to determine whether RFA has a role in treating patients with uterine fibroids. However, there is a paucity of well designed, randomized, controlled clinical trials with long-term follow-up demonstrating that RFA is superior to standard available treatment options for uterine fibroids. Thus, the RFA of uterine fibroids was not likely to be more beneficial for treatment 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 treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Three physician reviewers are board certified in obstetrics and gynecology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that the current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, 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. Afdhal and colleagues state, once-daily ledipasvir-sofosbuvir with or without ribavirin  was highly effective in previously untreated patients with HCV genotype 1 infection. Given that the patients viral load exceeds 6 million IU/mL, a 12 week course of Harvoni is clinically indicated. While the Health Plans clinical criteria recommends Viekira Pak plus ribavirin, Harvoni would be the preferred regimen for treatment of this patients hepatitis C infection. Harvoni is a single pill regimen whereas Viekira Pak plus ribavirin requires use of multiple drugs and pills, up to 10 pills a day. The potential for drug-drug interactions is significant with Viekira Pak plus ribavirin. Moreover, Viekira Pak can have significant side effects that are not anticipated with Harvoni monotherapy. Finally, Harvoni is the least complicated drug regimen, one pill, once a day versus ten pills throughout the day. For all these reasons, the requested Harvoni for 12 weeks is medically necessary for 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 physician is board certified in internal medicine with sub-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 electrical bone growth stimulator for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that there is a lack of support for the device at issue in this patients case.  The current literature supports electrical stimulation for healing of long bone nonunion or fresh fractures with significant risk factors.  However, similar literature does not exist for healing of sesamoid bone stress fractures in the foot.  Furthermore, the imaging study does not support the diagnosis of a stress fracture of the sesamoid bone.  The MRI report indicates presence of a bipartite sesamoid.  In light of the foregoing, the request for a bone growth stimulator is not supported by the literature.  As such, the electrical bone growth stimulator was not likely to have been of greater benefit than other treatment options.Final Result: Three reviewers determined that the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in orthopedic surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reduction mammoplasty for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation supports the requested services in this clinical setting.  The patient has well-documented, chronic back and neck pain with failure of reasonable conservative management, including chiropractic treatment.  Her activities of daily living are significantly affected with respect to her occupation.  Her examination and planned degree of resection are supportive of her significant macromastia.  Her condition of macromastia is causing functional problems, and she would likely benefit significantly from reduction surgery.  Breast reduction is a well-known procedure that directly addresses functional compromise.  The current medical evidence supports the requested services in this patients case.  All told, the requested reduction mammaplasty is medically indicated for the treatment of this patient.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 physician reviewer is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral automated whole breast ultrasound for evaluation of the enrollees medical condition. Findings:  The physician reviewer found that the addition of screening ultrasound or MRI to mammography in women at increased risk of breast cancer resulted in not only a higher cancer detection yield but also an increase in false-positive findings. The American College of Radiology (ACR) has rated the various modalities in terms of appropriateness to screen for breast cancer. The ACR states, Supplemental screening with US for women with intermediate risk and dense breasts is an option to increase cancer detection. In this particular patient, the dense breast tissue is a factor, especially in view of her strong family history of breast cancer. The Health Plan had suggested that a targeted screening sonogram to the areas of concern would have been the preferred option but in this patients case there were no specific areas of concern. Final Result: The reviewer determined that the services at issue were medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one is board certified in diagnostic radiology 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

An enrollee has requested authorization and coverage of Harvoni 90-400 mg for 12 weeks for treatment of the enrollees 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The patient should be considered treatment-naive due to failure of interferon with ribavirin rather than PEG-interferon with ribavirin; the guidelines specify that failure of PEG-interferon is required to be considered treatment-experienced. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic Hepatitis C Genotype 1 regardless of fibrosis stage.  AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment.  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: Physician reviewer number one 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 authorization and coverage for a 24 week course of Daklinza and Sovaldi for treatment of the enrollees 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 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, specific to the patients circumstance (genotype 3, peginterferon/ribavirin treatment-experienced patients without cirrhosis), the two following options are recommended: Daily daclatasvir (60 mg) plus sofosbuvir (400 mg) for 12 weeks or daily fixed-dose combination of sofosbuvir (400 mg)/velpatasvir (100 mg) for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials. Although treatment is needed, a 24 week course of Daklinza and Sovaldi is not supported in this patients case. Final Result: The reviewer determined that the requested medication regimen 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for genetic testing for evaluation of the enrollees risk for cancer. Findings:  The physician reviewers found the patient has a personal history of multiple polyps and villous adenoma. The patient has a family history of colon cancer in father and paternal grandfather and a paternal aunt with breast cancer. Given that this patient has had multiple polyps removed, and most recently was found to have villous adenoma, genetic testing is likely to be more beneficial than standard testing when you consider her personal and family history. The only detail that does not fit the Amsterdam II criteria for Lynch syndrome is that paternal aunts breast cancer is not a classic Lynch syndrome related cancer, even though breast cancer has been found in patients with some patients with Lynch syndrome. Final Result: Two of three reviewers determined that the requested testing is 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Femring for treatment of the enrollees symptomatic menopause. Findings:  The physician reviewer found that Femring is a systemic hormone therapy that contains a higher dose of estrogen than any other vaginal estrogen including Estring, Vagifem, and other topical estrogen treatments. Femring is indicated for patients with menopausal vasomotor symptoms in addition to vaginal changes. The available therapies are equally efficacious for vaginal atrophic changes. Vaginal estrogen is most commonly used in very low doses for the management of vaginal atrophy (now known as genitourinary syndrome of menopause [GSM]). Higher doses of vaginal estrogen can be used to treat vasomotor symptoms, much like any of the preparations for systemic use. Given these findings, Estring or other topical estrogen therapies on this patients Health Plans formulary can be used with her Evista, since those medications are not considered systemic therapy. 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for hyperbaric oxygen therapy. Findings:  The physician reviewer found that the use of hyperbaric oxygen therapy for treatment of this patients medical condition is supported by peer reviewed literature. The patient experienced bilateral ischemic skin flaps following his rhytidectomy. The submitted records indicated that the patient had struggling vascularity to his skin flaps. Ischemic skin flaps are known possible complications following rhytidectomy. The initial measures attempted included suture removal to lessen the tension on the flaps. With continued ischemia, the patient was recommended for hyperbaric oxygen treatment and he underwent this treatment. A study by Freidman and colleagues demonstrated that hyperbaric oxygen therapy, either alone or in combination with other modalities, should be considered when treating compromised flaps in certain situations. In this patients case, the patient had compromised skin flaps and the hyperbaric treatment was used in conjunction with other measures to improve skin survival. A retrospective study by Larson and colleagues concluded the following, This study provides clinical data characterizing and supporting the application of hyperbaric medicine to aid in the viability of compromised flaps.  The medical literature supports the use of this adjunctive treatment to lessen the degree of necrosis, as in this patients case. 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested implantation of the ExPRESS mini glaucoma shunt for treatment of the enrollees glaucoma.  Findings: Three physician reviewers found that there is a lack of independent medical data establishing the superior efficacy of the Ex-press mini glaucoma shunt implantation for treatment of glaucoma. While this procedure appears promising, in order for the patient to be considered for this procedure, the standard form of treatment for glaucoma should be exhausted.  In the records provided, there is no indication that this has taken place. Therefore, the implantation of the ExPRESS mini glaucoma was not likely to be of greater benefit than other available standard therapies for treatment of the patients glaucoma.Final Result: Three reviewers determined that the procedure at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: All three physician reviewers are board certified in ophthalmology 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.