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 12 weeks for treatment of her chronic hepatitis C virus genotype 1b.  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 non-liver-related conditions. This applies regardless of fibrosis stage or viral load. Per the AASLD and IDSA guidelines, noncirrhotic genotype 1 patients who have failed therapy with interferon and ribavirin should be re-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. The AASLD/IDSA guidelines also cite data showing increased survival with earlier treatment. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 12 week course of Harvoni for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. Harvoni carries the highest American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendation of Class I, Level A for treatment of HCV patients. In this case, there is documentation of progressive hepatic fibrosis. His fibrosis score meets classification per AASLD/IDSA guidelines as High Priority for medically necessary treatment. Although Viekira Pak is the Health Plans preferred therapy, Harvoni is medically necessary in this clinical setting given the patients multiple prescriptions and their drug-drug interactions with Viekira Pak. 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 gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks.  All told, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C virus.  Findings:  The physian 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 non-liver-related conditions. Per guidelines, treatment-naive genotype 3 patients should be treated with one of three regimens: Sovaldi/Daklinza for 12 weeks, Sovaldi/ribavirin with peginterferon for 12 weeks, or Sovaldi/ribavirin for 24 weeks.  Harvoni is not U.S. Food and Drug Administration (FDA) approved for treatment of genotype 3 and is not recommended by the guidelines, which note that the ELECTRON-II trial showed 64% cure rate with the requested regimen of Harvoni for 12 weeks. The activity of ledipasvir (part of Harvoni) against genotype 3 hepatitis C has been shown to be weak.  Although treatment is indicated in this case, and AASLD guidelines cite data showing increased survival with earlier treatment, alternatives for safe and effective therapy are available and recommended by AASLD. For these reasons, the requested treatment with Harvoni for 12 weeks is not supported as medically necessary for the treatment of this patients hepatitis C infection. 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 internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Orthovisc injection to the right knee for treatment of the enrollees moderate chondromalacia of the right knee.  The physician reviewer found that overall, the scientific evidence for the use of a repeat viscosupplementation injections series demonstrates that there may be continued improvement in some cases that otherwise would result in total knee arthroplasty. Pagnano and Westrich performed a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee. The authors concluded that repeat courses of the hyaluronans are safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, a study by Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment was efficacious during a 54-month follow-up period in continuing to delay time for a total knee arthroplasty in patients with knee osteoarthritis. Considering the risk of complications with total knee arthroplasty, a repeat a series of Orthovisc injections is medically reasonable and appropriate. As such, the Orthovisc injection to the right knee is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical services and hospital stay on an emergent basis. The physician reviewer found that submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the dates in question. Upon review of the submitted medical records, the patient presented with a several year history of chronic regional pain. The patient does not have demonstration of instability in flexion extension films. There is no documentation of fractures or scoliosis. Moreover, the demonstrated spinal stenotic changes, central and neural foraminal are referenced in the anatomical studies but they can be dealt with in a patient without instability through a more limited posterior approach without fusion. In sum, the patient was not experiencing 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. Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care. 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: 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 hepatitis C virus (HCV). Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity of the requested medication. In this case, the patient meets American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines for immediate HCV eradication with the highest priority.  The patient is currently being treated with medication that is contraindicated with the concurrent use of Harvoni.  Per the Drugs.com, drug interaction between this medication and dasabuvir (Viekira) are noted as a Major interaction. However, interaction between this medication and sofosbuvir (Harvoni) are noted as a Moderate interaction. The benefit of treatment for HCV with Harvoni with moderate interaction outweighs non-treatment. Given that Harvoni and this medication have a Moderate interaction, Harvoni for 12 weeks is medically necessary for this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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

An female enrollee has requested water circulating cold pad with pump for treatment of her right knee status post total knee arthroplasty. Nature of Statutory Criteria/Case Summary:   Three physician reviewers found that a review of the current medical literature on continuous cryotherapy after total knee arthroplasty resulted in a paucity of high quality data. Several recent meta-analyses failed to demonstrate any significant improvements in postoperative range of motion, reduced blood loss or reduced postoperative drainage with continuous cryotherapy over standard ice packs. A systematic review by Cina-Tschumi concluded that solely an analgesic effect was demonstrated by the use of continuous cooling. Another systematic review by Adie and colleagues concluded that, despite some early gains, cryotherapy after total knee arthroplasty yields no noted lasting benefits. All told, the water circulating cold pad with pump was not likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy. 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 reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to mammography has gained popularity due to an associated decrease in callbacks and increased rate of detection of small cancers.  This improvement using tomosynthesis is due to the tomographic feature of the technique and associated ability to separate out superimposed dense breast tissue from potential pathology.  All told, the addition of breast tomosynthesis was likely to have been of greater benefit in this patients case than two-dimensional mammography alone.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: Reviewers 1, 2, and 3 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 requested surgery on the hand 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.  The likelihood of improvement of small finger proximal interphalangeal (PIP) joint contractures with any treatment is guarded at best.  A study by researchers found that using night progressive static and daily dynamic orthoses as an exclusive treatment during the proliferative phase led to significant improvements in the PIP joint active extension.  According to other researchers, static progressive and dynamic splints are considered effective non-operative interventions to treat stiff fingers.  The patient will be best served with static and dynamic splinting.  All told, the requested surgery on the hand 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 plastic surgery with sub-specialty certification in surgery of the hand 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 contrast-enhanced cardiac computed tomography for evaluation of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has significant coronary risk and no documented symptoms suggestive of coronary ischemia.  In this circumstance, guidelines to evaluate and manage cardiac risk are available, periodically updated and are endorsed by several national organizations.  The current guidelines do not recommend the use of contrast-enhanced cardiac computed tomography as a screening test to further assess coronary risk.  Cardiac outcomes using treatment based on coronary computed tomography scanning results have not been demonstrated to be incrementally better compared to treatment based on a combination of clinical risk profiling and standard lipid analysis using current guidelines.  All told, the requested contrast-enhanced cardiac computed tomography is not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are 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 internal medicine with sub-specialty certification in cardiovascular disease 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 12 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that the current medical evidence supports 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.  Per the guidelines, 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 requested medication is likely to prevent further development and progression of fibrosis.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi for 24 weeks for treatment of his chronic hepatitis C virus genotype 3a.  Findings:  The physician reviewer found that the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines state that immediate treatment is assigned the highest priority for those patients with advanced fibrosis (Metavir F3), those with compensated cirrhosis (Metavir F4), liver transplant recipients, and patients with severe extrahepatic hepatitis C. The AASLD/IDSA guidelines also endorse daily Sovaldi and weight-based ribavirin for 24 weeks as an alternative regimen for treatment naive patients with hepatitis C virus genotype 3 infection who are interferon ineligible. Thus, the requested Sovaldi for 24 weeks is medically necessary for treatment of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested laboratory testing for evaluation of her medical condition. Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this patients case.  A review of the medical literature finds that the predictive value of the presence of various mutations for directing the duration of anticoagulation is low.  There is a lack of trials comparing routine and prolonged anticoagulant treatment in patients who test positive for various mutations.  Given this lack of evidence, testing for such genetic variations to guide duration of anticoagulant therapy is not supported by the medical literature.  Thus, laboratory testing performed was not likely to have been more efficacious than other modalities.   Final Result: Three physician reviewers determined that the services at issue were not likely to be more beneficial for evaluation 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 internal medicine 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.