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 her 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. This applies regardless of fibrosis stage or viral load. Per guidelines, non-cirrhotic genotype 1 patients who have failed PEG-interferon and ribavirin 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. The recommendations are the same if the patient is considered treatment-naive.  AASLD/IDSA guidelines cite data showing decreased 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested lumbar spinal fusion for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient presents with persistent and worsening low back pain radiating into the left lower extremity. The patient reports functional difficulty in work and daily activities. Clinical examination findings are consistent with imaging evidence of disc pathology. There is imaging evidence retrolisthesis reported by the radiologist and the treating physician. Detailed evidence of at least six months of reasonable and/or comprehensive nonoperative treatment protocol trial and failure has been submitted. However, there is no radiographic evidence of spinal segmental instability on flexion and extension x-rays meeting instability criteria of 4.5 mm of translational movement. There is no discussion or imaging evidence supporting the need for wide decompression that would result in temporary intraoperative instability and necessitate fusion. Therefore, the requested lumbar spinal fusion 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 orthopedic 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 intravenous immune globulin (IVIG) therapy for treatment of her medical condition.  Findings:  Two physician reviewers found that clinically it would appear that this patient does not have full blown Sydenhams chorea, but rather mild tics and chorea. The literature discussed use of cephalosporins rather than penicillins as being more effective. The medical literature also suggests the use of valproic acid, haloperidol, and carbamazepine as symptomatic treatment. None of these modalities have been tried. There is some literature supporting the use of IVIG. IVIG has been reported in multiple case reports and small series to be somewhat helpful as is plasma exchange; based on the theory of molecular mimicry leading to an immune attack on the basal ganglia. Given that IVIG therapy is generally reserved for more symptomatic cases that have been refractory to standard therapy, I find that IVIG is not more likely to be effective than standard treatment.   Final Result: Two 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:   All three reviewers are board certified in neurology 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 inpatient mental health treatment and electroconvulsive therapy for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the medical record indicates that the patient continued to have many of the symptoms that prompted the admission.  She was scheduled for electroconvulsive therapy the next morning.  Thus, it was safe, appropriate and consistent with good medical practice to have the patient remain in the hospital overnight.  The following day, the electroconvulsive therapy was well tolerated.  The documentation indicated that the patient had no side effects from this course of therapy and although she remained depressed and anxious, her mood was improved.  Thus, it appears the acute psychiatric syndrome had resolved.  Further, she was stable on her medications, well-supported at home and familiar with electroconvulsive therapy, which can be safely delivered in the outpatient setting.  In sum, inpatient mental health treatment and electroconvulsive therapy provided initially was medically necessary as they were reasonably expected to improve the patients condition and prevent a more serious episode of illness or prompt re-admission.  However, the medical records fail to demonstrate the medical necessity of the services at issue provided subsequent to the initial course of treatment.  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 breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides significant advantages to radiologists, particularly in cases of dense tissue.  This has resulted in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional images was likely be of greater benefit to this patient than had the examination been done with the two-dimensional technique alone.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three  reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient hospitalization for treatment of his medical condition. Findings: The physician reviewer found that although the patient was not suffering from an acute psychiatric syndrome, his presentation was consistent with the conceptualization of grave disability as he had significant impairment across multiple domains. Since he  remained debilitated by psychiatric symptomatologies, an inpatient residential stay was indicated.  Per the medical records, treatment could not have been safely or effectively delivered in a setting less restrictive than the inpatient venue at the time. The patient was engaged in active treatment delivered in accordance with a treatment plan that was reasonably expected to improve his condition and prevent a more serious episode of illness. In sum, inpatient hospitalization was medically indicated for the treatment of this patient.  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.
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 (HCV). Findings:  The physician reviewer found that while this patients records do not support advanced fibrosis, the medical necessity of HCV treatment, as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations, and the medical appropriateness of therapy, exist irrespective of fibrosis score.  AASLD/IDSA guidelines, underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). This patients life expectancy exceeds this limit. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with this patients characteristics. For these reasons, the requested medication 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar medial branch blocks for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  In the documentation available for review, the provider does not document a pain diary for medial branch block done previously.   The literature indicates that a diagnostic medial branch block is necessary prior to radiofrequency ablation; specifically using a pain diary for the day to verify when the local anesthetic wore off.  Moreover, the submitted records lack details regarding the radiofrequency ablation procedure also completed.  No rationale was given for a repeat medial branch block that would be necessary after radiofrequency ablation. Therefore, the requested lumbar medial branch blocks are not medically necessary for treatment of the patients medical condition.   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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for medical evaluation of her breast examination.  Findings:  Two physician reviewers found that researchers found the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Another medical study investigated the effect of integrated 2D and 3D mammography in population breast cancer screening. They found that integrated 2D and 3D mammography improves breast cancer detection and has the potential to reduce false positive recalls. The literature does support the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, upon review of the submitted documentation, the use of breast tomosynthesis for this patient was likely to be more beneficial than 2D imaging alone.   Final Result: Two reviewers determined that the service at issue was 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:  One reviewer is board certified in radiology and is actively practicing. Two reviewers are board certified in radiology with sub-specialty certification 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:  An enrollee has requested stem cell treatments for treatment of his medical condition. Findings:  Three physician reviewers found that stem cell therapy for the treatment of cerebral palsy is in its theoretical infancy with a lack of adequate clinical trials. The type of cells, method of introduction, and dosing is not yet clear. At this time, there is a lack of general agreement about the type of stem cells to be used such as mesenchymal, umbilical cord, or bone marrow derived. According to researchers Recent advances in regenerative medicine suggest that the transplantation of stem cells, including embryonic stem cells, neural stem cells, bone marrow mesenchymal stem cells, induced pluripotent stem cells, umbilical cord blood cells, and human embryonic germ cells, focusing on the root of the problem, may provide the possibility of developing a complete cure in treating [cerebral palsy] CP. However, safety is the first factor to be considered because some stem cells may cause tumorigenesis. Additionally, more preclinical and clinical studies are needed to determine the type of cells, route of delivery, cell dose, timing of transplantation, and combinatorial strategies to achieve an optimal outcome. Given the lack of adequate evidence for its efficacy, and the potential for adverse events, stem cell treatments were not and are not likely 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 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:   One reviewer is board certified in neurology with sub-specialty certification in pain medicine and metabolism and is actively practicing. Two reviewers are board certified in neurology 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 removal of tissue at the base of the tongue (coblation or radiofrequency volume reduction) for treatment of the enrollees sleep apnea. Findings:  Three physician reviewers found that studies support adenotonsillectomy (AT) as the recommended first-line treatment for pediatric obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy. The majority of studies establish that AT results in improvement for patients with severe OSA in most cases. In this patient, tonsillar hypertrophy was not documented. There is limited literature evaluating radiofrequency tongue ablation in pediatric patients. As such, there is inadequate data to establish that the tongue base reduction procedure was likely to result in a superior clinical outcome in this setting.  All told, radiofrequency tongue ablation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested sensory based occupational therapy for treatment of the enrollees medical condition.Findings: The medical evidence indicates that sensory based interventions can be very effective for children with autism spectrum disorder and behaviors including emotional regulation.  The study by Pfeiffer and colleagues included blinding comparison, and showed that sensory integration interventions helped with autistic tendencies and engagement in therapies.  The systematic review by Watling and Hauer found that sensory integration techniques can help with social interactions and mannerisms.  In this case, the enrollee had sensory based occupational therapy in the past and was making better progress.  All told, the requested sensory based occupational therapy 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 reviewer is board certified in developmental-behavioral pediatrics, 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 surgical breast augmentation for treatment of her gender dysphoria.  Findings:  The physician reviewer found that the patient is a transgender female with well-documented gender dysphoria who has been undergoing female transitioning for an extended period of time with hormonal therapy. Based upon the clinical evidence provided, despite extensive hormonal therapy, the patient does not have evidence of sufficient breast development consistent with adult female anatomy. The American Society of Plastic Surgeons (ASPS) has adopted the following definitions: Cosmetic surgery is performed to reshape normal structures of the body in order to improve a patients appearance and self-esteem. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance.  In this patients case, she is well-documented to have gender dysphoria; thus, her external anatomy should be more consistent with a female than a male. As such, the requested surgical breast augmentation is medically necessary for treatment of her gender dysphoria. Currently, her examination and photographs depict a lack of breast development and is more consistent with male anatomy. Thus, this should be considered breast reconstruction of a patient with lack of breast development. The abnormal structure of the body is caused by a lack of adequate response to hormonal therapy, a developmental abnormality. Based on the photographs and medical documentation provided, the patient has a significantly abnormal appearance and any appropriate surgical correction would attempt to obtain a more normal appearance and is likely to result in more than minimal improvement. As such, the requested service is medically necessary and considered reconstructive in nature. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and is reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number three 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.