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

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Synvisc One injection for treatment of her right knee pain.  The physician reviewer found that review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the Synvisc One injection. There is a lack of studies in the medical literature documenting clinical effect from hyaluronan injection. Rutjes and colleagues performed a meta-analysis of the efficacy of viscosupplementation involving 12,667 patients with knee osteoarthritis. The authors concluded In patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events. In addition, the American Academy of Orthopaedic Surgeons practice guidelines for the treatment of osteoarthritis of the knee states, We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee. For the reasons provided, the service at issue was not medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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: 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.  Two physician reviewers found that according to the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Treatment-naive patients are recommended to be treated with Harvoni, a Class I, Level A recommendation. 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. Additionally, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. Lower sustained virologic response rate has been reported with Harvoni in patients with cirrhosis (Bourliere, et al).  Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary in this case.  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 certification in gastroenterology and is actively practicing.  Two 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 her hepatitis C virus.  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 Infectious Diseases Society of America (IDSA) recommendations for testing, managing, and treating hepatitis C, all patients with chronic hepatitis C should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. 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 HCV genotype 1 regardless of fibrosis stage. In addition, treatment of patients before they progress to F3 or F4 fibrosis is advantageous. In sum, the request for Harvoni has been established as medically necessary in this clinical setting.  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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a pneumatic compressor with calibrated pressure and pressure pneumatic appliance for treatment of her left knee status post total knee replacement.  Three physician reviewers found that the pneumatic compressor with calibrated pressure and pressure pneumatic appliance was not likely to be more effective for this patient than other available treatment options. There is a lack of medical literature supporting pneumatic cooling devices after total knee surgery. There is a lack of defined benefit with treatment of pneumatic compressor with calibrated pressure and pressure pneumatic appliance over the use of conventional ice packs to reduce swelling. In this clinical setting, the standard of care is the use of conventional ice packs. The medical records and medical literature do not support the use of pneumatic compression cold therapy status post total knee surgery. All told, the device at issue 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested topographic genotyping (PathFinder TG Test) for evaluation of his pancreatic lesion. Two physician reviewers found that the testing at issue was not likely to be more effective for this patient than other available treatment options. This test was ordered in the context of a patient with a small pancreatic cyst. In this clinical setting, the standard of care is close surveillance with observation with an increase in size triggering a more invasive intervention. Recent guidelines indicate that molecular markers remain an emerging area of research, and the diagnostic utility of these tests is uncertain. For the reasons provided, the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   Final Result:  Two reviewers determined that the testing at issue was 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: One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and is actively practicing. One reviewer is board certified in medical oncology and is actively practicing.  One reviewer is board certified in medical oncology and is 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:   The parent of an enrollee has requested the RT300 functional electrical stimulation (FES) cycle rehabilitation system for treatment of the enrollees unilateral upper extremity paralysis.  Two physician reviewers found that the equipment at issue was likely to be more effective for this patient than other available treatment options. Functional electrical stimulation (FES) of the central and peripheral nervous system can use these intact neuromuscular systems to provide therapeutic exercise options to allow functional restoration and to manage medical complications following SCI. The use of FES for the restoration of muscular and organ functions may significantly decrease the morbidity and mortality following [spinal cord injury] SCI. According to the documentation submitted for review, the patient presents with a spinal cord injury secondary to transverse myelitis. There is support in the peer-reviewed literature demonstrating improvement in motor and functional parameters. Therefore the FES cycle rehabilitation system was clinically indicated for treatment and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Final Result: Two reviewers determined that the equipment at issue was likely to be more beneficial for treatment 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 child neurology and is actively practicing. One reviewer is board certified in neurology with special qualification in child neurology and is actively practicing.  One reviewer is board certified in pediatric rehabilitation medicine and is 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 laparoscopic radiofrequency ablation for treatment of her symptomatic uterine fibroids. Three physician reviewers found that the requested services are not likely to be more effective for this patient than other available options. There are an number of non-surgical and surgical treatments options for heavy periods and fibroids, including nonsteroidal anti-inflammatory drugs (NSAIDs), progestins, oral contraceptives, Lupron, uterine artery embolization, minimally-invasive surgery such as laparoscopic myomectomy, and abdominal myomectomy or hysterectomy, which can also be done in a minimally-invasive fashion (mini-laparotomy). Radiofrequency ablation is a new alternative, with initial small studies indicating that in appropriate patients it may become a reasonable surgical alternative for patients with fibroids. Given that this is a relatively new procedure, the studies available are mostly observational studies. Although this procedure may be an option for patients with fibroids in the future, there is still insufficient evidence available at this time to conclude that it is more beneficial than other available treatments. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than other standard therapies.  Final Result: Three reviewers determined that 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 obstetrics and gynecology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested urgent care services on an emergent basis. The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought immediate medical attention on the date in question. According to the documentation submitted for review, the patient did not present with a fever or serious impairment to bodily functions or serious dysfunction of any bodily an extended period of time and reported that cough suppressants were alleviating her symptoms. The patient was diagnosed with sinusitis and given antibiotics and antihistamine prescriptions.  A prudent layperson would not have sought medical attention on the date of service in question because the absence of immediate medical attention could not reasonably be expected to result in placing the patients health in serious jeopardy. All told, the patients symptoms would not lead a prudent layperson to believe their health to be in imminent danger. In sum, the patients symptoms 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested proton beam radiation therapy (PBRT) for treatment of his metastatic squamous cell carcinoma of the neck with unknown primary.  Three physician reviewers found that proton beam radiation therapy is not likely to be more effective for this patient than other available options. There is a lack of evidence to suggest that treatment of the patients head and neck cancer with proton beam radiation therapy will be more beneficial than standard treatment with photons and intensity modulated radiation therapy (IMRT). The National Comprehensive Cancer Network (NCCN) guidelines state that standard therapy for treatment of head and neck cancer is IMRT. The American Society of Radiation Oncology (ASTRO) emerging technology committee specifically stated that there is insufficient data to recommend proton therapy for routine head and neck radiation outside of clinical trials. Moreover, a recent review article stated that there are no major comparative clinical studies or randomized trials between proton and photon therapy in the treatment of head and neck cancer. The vast majority of patients with head and neck cancer are able to tolerate treatment with photon therapy with no major complications and there is insufficient data to suggest that outcomes are improved with proton treatment. For these reasons, treatment with proton beam radiation therapy is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapies. Final Result: Three 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 radiation 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Stelara for treatment of her Crohns disease.  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Despite the success of anti-tumor necrosis factor therapy in Crohns disease, there remains a need for biologic therapy that targets other immune pathways of disease.  Stelara is a fully human monoclonal immunoglobulin antibody which has been studied in two phase 2 randomized, double-blind, placebo-controlled trials in Crohns disease.  Per the literature, patients with an initial response to Stelara had significantly increased rates of response and remission with Stelara as maintenance therapy.  There is a lack of treatment options in this clinical setting, and the patient has responded to Stelara.  All told, Stelara is likely to be more efficacious than other treatment options.  Final Result:  Three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 three-dimensional x-ray (breast tomosynthesis) for evaluation of her medical condition.  Two physician reviewers found that in this patients case, the diagnostic procedure at issue was likely to have been superior over other modalities.  Per the medical evidence, digital breast tomosynthesis as part of the normal screening mammographic study is associated with a decrease in call backs as well as increased detection of small breast cancers when compared to digital breast mammography without tomosynthesis.  The addition of breast tomosynthesis to the routine standard mammographic views has proven very useful in screening populations.  All told, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  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. 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 Harvoni for treatment of her hepatitis C virus (HCV). Three physician reviewers found that per the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA), 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. AASLD/IDSA further state, The goal of treatment of HCV-infected persons 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, based on the guidelines cited above the patient should be approved for Harvoni for the treatment of HCV. Thus, Harvoni is medically necessary for this patient.  Final Result: Three reviewers determined that the requested medication is medically necessary for treatment.  Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation (TMS) for treatment of her major depressive disorder.  Two physician reviewers found that TMS treatment is not likely to be more effective for this patient than other available options. The U.S. Food and Drug Administration (FDA) has approved TMS for the treatment of treatment resistant depression. In this case, the patient has not been treated with appropriate dosages of antidepressants, nor is there evidence that this patient has been treated with augmentation strategies. Therefore, this patient cannot be considered treatment resistant. Specifically, the medication dosages that have been tried for this patient are low and fall short of the maximum dosages that are necessary to treat a patient with significant depression.  Therefore, there are available safe, standard therapies that are available to this patient that do not appear to have been tried. For the reasons provided, TMS services are not likely to be more beneficial than standard treatments for this patient medical condition. 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 psychiatry 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.