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 his chronic hepatitis C virus genotype 1a. Findings: Three physician reviewers found that currently, Harvoni is U.S. Food and Drug Administration (FDA) approved for the treatment of chronic hepatitis C genotype 1 infection in adults. In this patients case, there is documentation of hepatic fibrosis at Metavir F2. The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines define patients with Metavir F2 fibrosis staging as High Priority for hepatitis C virus eradication. Given this support, this patient meets the classification per AASLD/IDSA guidelines as High Priority for treatment. All told, the requested Harvoni is supported as medically necessary. Final Result: Three 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: The three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 3D digital x-ray of the breast (tomosynthesis) for evaluation of her palpable mass in the left breast.  Two physician reviewers found that this patient had bilateral silicone implants which make the breasts difficult to position and image in their entirety using conventional mammographic views. Usually the presence of a palpable mass is approached by standard mammography and ultrasound to follow. One advantage of tomosynthesis in this clinical setting is the ability to image the entire breast without significant or exaggerated compression. Also, the technique is valuable in the examination of the contralateral, asymptomatic breast for occult mass. The use of tomosynthesis in addition to standard digital mammography has gained acceptance in the past few years due to the preliminary experience of decreased callbacks and increased detection of small cancers. Thus, the 3D digital x-ray of the breast (tomosynthesis) was likely to have been more beneficial for evaluation of this patients palpable breast mass, the remainder of the symptomatic left breast, and the entire contralateral right breast, than any available modality. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: 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. 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. As such, the patients breast cancer screening with tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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 Lyrica for treatment of her fibromyalgia.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has contraindications to multiple preferred agents for fibromyalgia.  Lyrica is approved by the U.S. Food and Drug Administration and is indicated for the management of fibromyalgia.  This patients comorbid condition of end-stage liver disease limits her medication options.  There is sufficient support for the requested medication in this clinical setting.  All told, the requested medication Lyrica 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator for treatment of his obstructive sleep apnea. Two physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. The standard of care for the treatment of clinically significant OSA is CPAP, which has been documented to be effective treatment for this patient and has been tolerated in the sleep center. The vast majority of patients with OSA have significant obesity frequently bordering on morbid obesity. This patient is not obese. Patients who have OSA and are not obese frequently have positional sleep apnea that can be effectively treated with a vest containing a tennis ball to avoid supine sleep. On the basis of the reports from the sleep studies provided, positional sleep apnea has not be ruled out and there is no indication for the requested surgical procedure to implant an electrode and generator for vagus nerve stimulation until positional sleep apnea has been ruled out. Therefore, the request for incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator is not likely to be more beneficial than standard medical therapy in this clinical setting. 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: One reviewer is board certified in neurology with sub-specialty certification in sleep medicine and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in pulmonary disease 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 chiropractic visits for treatment of her medical condition. The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was treated for the same symptoms for a total of 19 office visits.  The treating chiropractors notes do not document an examination in the office notes submitted, and there is no documentation that a re-evaluation was performed.  The records do not include the necessary clinical documentation to warrant additional care, such as range of motion, palpation, and reflexes.  All told, the chiropractic visits 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 chiropractic orthopedics 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 Norco for treatment of her chronic pain. The physician reviewer found that although opioids are routinely used in chronic pain management, there is a lack of data demonstrating significant efficacy with their use on a long-term basis. After receiving hydrocodone for a short period of time, many patients become long-term or lifelong users. Consequently, hydrocodone is not indicated for routine pain management as in this clinical setting. All told, the requested Norco is not medically necessary for this patients chronic pain management. 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-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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested emergency room services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. Upon review of the submitted medical records, the patient presented with normal vital signs and no pain was elicited on physical examination. The patient denied tooth pain, ear pain or trauma. The medical record does not document that the patient was in acute distress. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe she was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in dispute. In this case, the patient presented with jaw pain. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. There was no risk to the patients airway and she was swallowing without difficulty.  There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested focal cryoablation surgery provided by an out-of-network provider for treatment of his prostate cancer. The physician reviewer found that cryosurgery is a thermal therapy involving freezing tissues to subzero temperatures leading to cold injury. Cryosurgery has been commonly utilized for treatment of prostate cancer.  Recent technological advances have allowed for the procedure to be done on an outpatient basis with 5-14 days of catheterization. The most common form of cryotherapy is total gland ablation, whereby the whole prostate gland is ablated. This is similar to other prostate cancer treatments such as radiation and surgery which involve treating the whole prostate gland. The National Comprehensive Cancer Network (NCCN) guidelines state that cryosurgery is a treatment option following failure of radiation therapy. It is not recommended as an initial treatment at this time. More research is needed to compare cryosurgery to prostatectomy and radiation therapy. This patient has intermediate risk prostate cancer with possible extracapsular extension on MRI. He has documented bilateral disease based on biopsies. He was offered radiation therapy (brachytherapy and external beam) and radical prostatectomy, both of which are widely accepted standards of care for treatment of localized prostate cancer. Based on the available clinical documentation and medical literature, focal cryotherapy would not be best option for long-term treatment of this patients prostate cancer. Thus, focal cryoablation surgery provided by an out-of-network provider was not medically necessary for treatment of this 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 urology 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 residential mental health and substance abuse treatment for his alcohol use disorder.   The physician reviewer found that based on the presentation and concerning history of alcohol consumption, this patient was at high-risk for complicated alcohol withdrawal.  Thus, a supervised detoxification was indicated.  During visits with his primary care provider the patient was tachycardic.  He was diagnosed with and treated for hypertension.  He was demonstrating psychiatric symptoms that prompted prescription of an antidepressant medication.  Upon presentation to the treatment facility, the patient was intoxicated.  His blood pressure was elevated.  He reported past withdrawal symptoms of nausea, shakes and sweats.  He had abnormal liver function tests and a microcytic finding on blood count.  He was treated with a chlordiazepoxide taper.  In sum, detoxification services in a residential setting were medically indicated and were expected to improve the patients condition.  Therefore, initial residential placement was medically necessary.  However, the medical records do not demonstrate the continued necessity of treatment in a 24-hour supervised.  The patient was motivated for recovery and had a supportive family.  He did not have legal sequelae from his drinking.  He did not use other substances.  He did not have a co-occurring psychiatric condition that would necessitate treatment in a setting other than the outpatient venue.  Of further significance, the patient had not pursued chemical dependency treatment in a less restrictive setting, such as community-based programming, outpatient services or partial hospitalization.  This is significant because modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment.  All told, residential mental health and substance abuse treatment initially was medically necessary, but not thereafter.  Final Result: The reviewer determined that 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Life Vest wearable cardioverter for treatment of her cardiomyopathy. Two physician reviewers found that placement of a prophylactic defibrillator is not recommended until a period of time, about 40 days after myocardial infarction has elapsed, where continued severe left ventricular dysfunction is documented to persist in spite of appropriate treatment. Placement of a prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve patient outcomes. Studies assessing the efficacy of prophylactic defibrillators early after diagnosis of myocardial infarction and reduced ejection fraction of 35% or less before ventricular function has had a chance to recover have not demonstrated improved outcome. A prophylactic wearable external defibrillator is indicated only if accepted criteria for an implantable defibrillator are met and an implantable defibrillator could not be placed, needed to be significantly delayed or required explantation. All told, the Life Vest wearable cardioverter defibrillator was not likely to have been more beneficial in treating this patients medical condition than standard modalities. 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:  All three reviewers are board certified in cardiology 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 chronic hepatitis C virus genotype 1b.  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and 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, which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Accordingly, the requested Harvoni is supported as medically necessary for treatment of this patients chronic hepatitis C virus.  Final Result:  Three 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 Harvoni for treatment of his hepatitis C virus (HCV). Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. In addition, the AASLD/IDSA guidelines state that High priority for treatment owing to high risk for complications include patients with fibrosis (Metavir F2). This patient has a Metavir of F2. Hence, treatment is indicated immediately. Moreover, guidelines support the use of Harvoni for treatment-naive patients with HCV genotype 1a infection. As such, the patients request for Harvoni is medically necessary.  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:   One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified 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.