Persius/hicric huggingface dataset:
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. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The peer reviewed literature cited above supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. According to Skaane and colleagues, 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. In addition, Caumo and colleagues examined center-specific effect of integrated 2D/3D mammography based on the screening with tomosynthesis or standard mammography (STORM) trial. The authors concluded the following Integrated 2D/3D-mammography significantly increased cancer detection for both screening services; potential reduction in false positive recalls (FPR) is likely to differ between centres with those experiencing relatively higher FPR most likely to benefit from 2D/3D-mammography screening. For the reasons provided, the breast tomosynthesis was likely to be more beneficial for evaluation of this patient than standard modalities.  Final Result:  Two reviewers determined that the diagnostic procedure 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: 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 Viekira Pak for treatment of his hepatitis C.  Two physician reviewers found that there is sufficient support for the requested medication in this clinical setting.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment of all patients with hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions.  If the infection is left untreated, it can lead to a variety of systemic complications such as renal disease and vasculitis, in addition to causing ongoing hepatic damage with further progression of fibrosis to cirrhosis.  Therefore, the requested Viekira Pak is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested ribavirin and sofosbuvir (Sovaldi) for treatment of her chronic hepatitis C virus genotype 2. Two physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, the recommended regimen for treatment naive patients with hepatitis C virus genotype 2 is daily sofosbuvir and weight-based ribavirin for 12 weeks. In addition, the guidelines cite three clinical trials demonstrating the safety and effectiveness of this medication regimen in patients with genotype 2 hepatitis C. Based on the provided records, published evidence of safety and efficacy in the published literature and clinical guidelines, the requested ribavirin and sofosbuvir (Sovaldi) should be approved as medically necessary for treatment of this patients medical hepatitis C virus.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Forteo for treatment of his osteoporosis with compression fracture.  The physician reviewer found that review of the submitted documentation establishes the medical necessity of the requested medication. Forteo is indicated for patients with osteoporosis at high risk for fracture. In this case, the patient presents with multiple vertebral fractures. Given the patients multiple vertebral fractures, he is at high risk for future fractures of the spine. In this case, the patient has fragility fractures and anabolic therapy is clinically indicated. Based on the clinical documentation submitted for review, Forteo is medically necessary for treatment of the patients medical condition. 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 endocrinology, diabetes 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested sumatriptan, 27 tablets per month, for treatment of her migraine headaches.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication quantity.  This patient has a history of high frequency episodic migraine versus chronic migraine. Her overall headache frequency is not described.  High frequency of use of acute abortive pain medications greater than two days per week can promote medication overuse headache.  Sumatriptan 100mg can be more effective than sumatriptan 50mg, and there are multiple other triptans to be selected from if needed.  Based on guidelines from the Academy of Neurology and the American Headache Society, the patient should be managed with preventive therapy.  There is a lack of support for the requested medication quantity in this clinical setting.  All told, the requested sumatriptan, 27 tablets per month is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that that the requested medication quantity 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 neurology 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 neuropsychological testing for evaluation of her medical condition. The physician reviewer found that neuropsychological testing is not medically necessary for treatment of the patients medical condition. The documentation submitted for review does not indicate that this patient has any acute neurological deficits that would require neuropsychological testing to diagnose. The neuropsychological testing performed previously indicated a diagnosis consistent with mild intellectual disability and depression, although the testing also revealed that her effort level was lower than expected. The documentation submitted for review does not indicate that she is suffering from a progressive dementia that would require follow-up testing. There also is no indication that she has suffered a stroke, epilepsy or mass lesion that might require neuropsychological testing to aid in the diagnosis. Based on the documentation provided, neuropsychological testing is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested testing is not medically necessary for evaluation 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 or Viekira Pak for treatment of her chronic hepatitis C virus genotype 1a.  Two physician reviewers 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, regardless of fibrosis, should be treated except those with life expectancy less than 12 months due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to 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. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is supported as medically necessary for treatment of this patients medical condition.  Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
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 her left bloody nipple discharge.  Two physician reviewers found that while there is a lack of long-term studies showing increased survival rates when mammography is supplemented with digital breast tomosynthesis, the technique has gained significant popularity due to improved detection of small cancers particularly in dense or heterogeneously dense breast tissue. For this reason, the addition of digital breast tomosynthesis to the typical four view screening digital mammographic study is more beneficial in well selected patients than digital screening mammography alone. As this patient presented with bloody nipple discharge, the use of digital breast tomosynthesis in addition to standard mammography was likely to have been more beneficial than any available technique. Final Result: Two reviewers 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: 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 Sovaldi/Olysio 12-week combination therapy for treatment of her hepatitis C.  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  The medical evidence supports treatment in all patients with hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The goal of treatment is to reduce all-cause mortality and liver-related health adverse consequences.  There is sufficient support for the requested medications in this clinical setting.  Therefore, Sovaldi/Olysio 12-week combination therapy is medically indicated for the treatment of this patient.  Final Result: Two reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a 12 week course of Harvoni for treatment of his chronic hepatitis C virus genotype 1b. Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C 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 patients. Current evidence supports treatment in all hepatitis C virus infected patients, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions. The goal of treatment of hepatitis C virus infected patients is to reduce all-cause mortality and liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma, by the achievement of virologic cure as evidenced by an SVR. Therefore, as per the FDA recommendation, the requested Harvoni for 12 weeks is supported as medically necessary for treatment of this patients medical condition. Final Result: Two reviewers 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: All three reviewers are board certified in internal medicine with sub-specialty certification in 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) services provided for treatment of his anorexia nervosa. The physician reviewer found that although the patient had a significant eating disorder complicated by global negative schemas and depressiveness, the clinical documentation provided did not support the medical necessity of the PHP services. During the treatment course, the patient demonstrated steady improvement.  The patient was in the action stage of treatment. His weight was up from admission. He was normotensive, with no orthostatic changes, bradycardia or tachycardia. He was taking classes two mornings per week and participating in social activities. The patient was reported to be eating 100% of his meals and, he was less depressed. The treatment team had a reassuring meeting with the patients family.  The patient denied any eating disordered behavior. His vital signs remained stable, he was 92% of his ideal body weight, and he was gaining weight on a positive trajectory. He was making his own meals and consistently following his meal plan, both within and outside the program. He was stable on an adequately dosed serotonergic enhancing medication. Although the patient continued to require long-term specialty care, there is a lack of evidence to suggest that he would have experienced a recrudescence of the symptoms if transitioned to a less restrictive setting, such as an intensive outpatient program (IOP). In sum, based on the documentation provided, the PHP services at issue were not medically necessary for treatment of the patients medical condition. 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 with sub-specialty certification in child and adolescent 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 the MyRisk Genetic Panel (81479) for evaluation of the enrollee, who has a history of breast cancer.  Three physician reviewers found that in this patients case, a portion of the services at issue was likely to have been of greater benefit than other alternatives.  Screening for BRCA mutations is indicated in individuals whose personal or family history predicts a high likelihood of finding one of these mutations. Identifying individuals who carry these mutations has clinical importance in that it mandates the adoption of special measures aimed at risk reduction.  Well-established guidelines identify those individuals in whom genetic screening is warranted.  This patient has a history of invasive ductal breast cancer, and as such is eligible for coverage for BRCA1 and BRCA2 testing.  However, the other genetic tests included in the MyRisk Genetic Panel were not indicated in this clinical setting.  Final Result: Three reviewers determined that a portion of the services at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The Health Plans denial should be partially 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested posterior tibial nerve stimulation (PTNS) for evaluation of the enrollees urinary urgency, frequency and nocturia.  Two physician reviewers found that the medical literature supports the use of PTNS as a third-line therapy for the treatment of urinary frequency, urgency and incontinence in those who have failed medical management (first and second line therapies). In this case, the use of PTNS based upon the patients limited medication trials and signs of improvement with only initial pelvic floor training would fall outside the standard of care. In sum, there is a lack of evidence supporting that PTNS would be more therapeutic than other available second-line therapies for this patient. For the reasons provided, PTNS was not and is not likely to be more beneficial than standard medical therapy in this clinical setting.  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 urology 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.