Persius/hicric huggingface dataset:
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:  Three physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  The records document cirrhosis, and Harvoni has been demonstrated to be effective for patients with cirrhosis.  This patient meets American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines for immediate treatment with highest priority.  Therefore, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  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. 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:  The parent of an enrollee has requested Nutropin AQ NuSpin 20 pen cartridge for treatment of the enrollees medical condition.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  There is a lack of clinical documentation of short stature, poor growth velocity, or poor adult predicted height.  Based on the information provided, the patient did not undergo a full, conventional two-agent provocative growth hormone test, with serial measurements for three to four hours of growth hormone levels in response to each of two agents.  Rather, one growth hormone response to clonidine and one response to L-Dopa were obtained.  The fact that the patient did not exhibit a robust growth hormone response to this abbreviated form of provocative testing does not prove that he is growth hormone deficient. Growth hormone provocative testing, even when performed completely, has poor sensitivity and specificity for a diagnosis of growth hormone deficiency in the absence of auxological data consistent with a growth disorder.  All told, the requested Nutropin AQ NuSpin 20 pen cartridge is not medically indicated for the treatment of this patient.  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 pediatrics with sub-specialty certification in pediatric endocrinology 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 requested Xiaflex for medical treatment of his Peyronies disease.  Findings:  The physician reviewer found that Peyronies disease is caused by scar tissue, called plaque, which forms along the length of the penis in the corpora cavernosa.  Depending on the severity of the condition, this condition can cause penile curvature with erection.  The curvature can make intercourse difficult and/or painful for the patient and his partner.  Potential treatments for Peyronies disease include surgery, minimally invasive treatment options, and medications.  The results for most previously available medications and minimally invasive therapies have been inconsistent or lacked empirical support for effectiveness.  The only options which have the potential to significantly reduce penile curvature in this patient are Xiaflex injections and reconstructive surgical therapy.  There is sufficient support for Xiaflex in this clinical setting.  All told, the requested medication Xiaflex 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 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 Harvoni for treatment of his hepatitis C. Findings: Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting. As noted by the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Initiation of treatment when patients have early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications.  All told, the requested medication Harvoni 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: 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 requested a 12-week course of percutaneous tibial nerve stimulation for treatment of her medical condition.  Findings:  Two physician reviewers found that percutaneous tibial nerve stimulation treatments are considered a standard third-line treatment option for overactive bladder per current guidelines.  In this case, the patient has failed first-line and second-line treatment options.  All told, the 12-week course of percutaneous tibial nerve stimulation was likely to have been superior over other treatment options.Final Result: Two reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in urology and is 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 requested magnetic resonance imaging (MRI) of the neck spine and back spine without dye for medical evaluation of his chronic back pain.  Findings:  The physician reviewer found that the clinical documentation submitted for review does not demonstrate that the patient has an abnormal neurologic exam or unequal reflexes on exam. In addition, there is no documentation of a course of physical therapy in the medical records provided. Based on the medical literature and clinical documentation provided, the request for MRI of the neck spine and back spine without dye is not medically necessary for evaluation of the patients medical condition.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 diagnostic radiology with sub-specialty certification in interventional radiology 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 requested Xiaflex for treatment of his Peyronies disease.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The patient is unlikely to experience resolution of the penile curvature without treatment.  He has failed other treatments.  The current medical evidence supports the requested medication in this clinical setting.  In this patients case, there is a lack of viable alternatives except a surgical procedure with uncertain outcome.  This condition causes significant impact on well-being and quality of life.  Xiaflex is standard of care for the treatment of this patient.  All told, Xiaflex 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 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 Sovaldi with ribavirin for treatment of his hepatitis C. Findings: Three physician reviewers found that the current medical evidence supports the requested medications in this clinical setting. Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment of all patients with chronic hepatitis C, except those with limited life expectancy due to non-liver-related comorbid conditions. Initiation of treatment when patients have early stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C. All told, the requested medications are medically necessary for the treatment of this patient. Final Result: Three 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: 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient level of care services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient was at risk for undue morbidity, self-harm and prompt re-admission to the acute level of care in the event of a premature discharge.  The patient had neither consolidated the treatment gains nor resolved the ambivalence necessary to successfully follow through with treatment in a less restrictive setting.  The disputed treatment course consisted of active treatment reasonably expected to prevent a more serious episode of illness while improving her condition.  All told, inpatient level of care services was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested collagen gel injections to be administered to both knees for treatment of his bilateral knee osteoarthritis.   The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. There is a lack of medical literature supported by double blinded studies with comparison to placebo demonstrating the efficacy of collagen gel injections. In the article by Burrage and colleagues, there is a description of the destructive effect on proteoglycans and type 2 collagen by inflammatory cytokines, interleukin 1 and tumor necrosis factor alpha stimulating the production matrix metalloproteinases (MMPs) enzymes that can degrade proteoglycans and extracellular matrix. Collagenases such as MMP1 and MMP13 limit the rate of collagen degradation. While this basic science has been established, the authors state as yet there have been no effective clinical inhibitors identified. The authors provide the opinion that further study and knowledge of molecular mechanisms may provide new therapeutics. Based on the medical literature and clinical documentation provided, the request for collagen gel injections to be administered to both knees is not medically necessary for treatment of the patients medical condition.  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 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 services in a proposed treatment plan for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  The patient has a maxillofacial skeletal deformity which has resulted in a functional deficit.  Her deformity cannot be corrected with orthodontics alone.  Thus, she will require orthognathic surgery.  The proposed surgery is likely to result in improved musculoskeletal, dento-osseous and soft tissue relationships.  The proposal includes a segmental Lefort 1 osteotomy and sagittal split osteotomy of the patients mandible.  The request is also for the fabrication of two oral surgical splints and for a co-surgeon for the procedure.  The performance of a segmental Lefort 1 osteotomy and a sagittal split osteotomy of her mandible is appropriate given the patients diagnosis.  The fabrication of two oral surgical splints is also indicated for the proposed surgery.  One splint is used as an intermediate splint and the other as a final splint which allows positioning of her jaws in their appropriate position.  The patients oral surgeon has also requested the use of a co-surgeon.  Given the nature of the recommended procedure, the presence of a co-surgeon is appropriate.  All told, the requested services in the proposed treatment plan are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in oral and maxillofacial 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Rozerem 24mg for treatment of her medical condition.  Findings:  The physician reviewer found that the current medical evidence does not support the requested medication dosage in this clinical setting.  Per the medical records, patients with insomnia should receive therapy for any medical condition, substance abuse, psychiatric illness, or sleep disorder which may be precipitating the insomnia.  Cognitive behavioral therapy is recommended as an initial therapy for patients who continue to have insomnia.  If a combination of medication and cognitive behavioral therapy is needed, six to eight weeks of a short-acting medication is appropriate.  The U.S. Food and Drug Administration has approved Rozerem 8mg for the treatment of insomnia.  In this patients case, she is requesting Rozerem 24mg.  There is a lack of support for the requested medication dosage in this clinical setting.  The documentation does not support that this patient has been evaluated for medical conditions, psychiatric illness, substance abuse or sleep disorder which may be exacerbating or precipitating the insomnia.  All told, the requested Rozerem 24mg is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication dosage 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 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 requested attended polysomnography for medical evaluation of his sleep apnea.  Findings:  The physician reviewer found that the sleep study was medically necessary for this patient because of the findings on the overnight oximetry suggesting OSA and because the polysomnography was the only method available to diagnose positional OSA in this patient. Based on the medical records submitted and the peer-reviewed literature, the attended polysomnography was medically necessary for evaluation of the patients medical condition.Final Result: The reviewer 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: The reviewer is board certified in internal medicine with sub-specialty certification in pulmonary 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested Oasis wound matrix (skin graft) for medical treatment of his medical condition.  Findings:  Three physician reviewers found that in this case, the wound had not failed other methods of management and thus was not a chronic, non-healing wound.  Furthermore, the application of the Oasis wound matrix to a wound measuring 0.3 cm in maximal dimension is an excessive use of the product.  All told, Oasis wound matrix (skin graft) was not likely to have been more effective than other treatment options.Final Result: Three 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: Reviewers 1, 2, and 3 are board certified in surgery 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 full body computed tomography (CT) or full body magnetic resonance imaging (MRI) for evaluation of his peripheral neuropathy. The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested services. There is no medical literature that addresses medical necessity or lack of medical necessity, for whole body MRI or CT scan for the evaluation of numbness. Numbness can be caused by disorders of the peripheral nerves, nerve roots, spinal cord or brain. The evaluation of numbness is dictated, initially, by the patients symptoms and findings on examination. If disorders of the peripheral nerves or nerve roots are suspected appropriate, evaluation would include electrodiagnostic studies and nerve conduction studies, laboratory evaluation and focused imaging studies, typically MRI. The latter are used to evaluate possible nerve or nerve root impingement based on the results of the clinical examination and electrodiagnostic studies. If the patients symptoms and physical findings suggest sensory loss as a result of a disorder of the brain or spinal cord, MRI studies of these parts of the nervous system are appropriate. In general, CT scanning of the nervous system is less likely to demonstrate any cause for numbness or sensory loss than MRI. In addition, whole body CT scanning involves significant exposure to ionizing radiation. In this case, electrodiagnostic evaluation and/or a lumbar MRI as recommended by his treating providers are medically reasonable and appropriate. Thus, the requested services are not medically necessary for evaluation of the patients medical condition.  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 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.