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

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program level of care for treatment of her behavioral health conditions.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was processing her trauma while the updated treatment plan noted that she was successfully articulating and implementing coping skills.  The patient was motivated for treatment and had a safe residence and supportive family.  During the episode of illness, she had not previously engaged in evidence-based therapies for posttraumatic stress disorder and bipolarity, such as cognitive processing therapy or prolonged exposure and cognitive behavioral therapy, family therapy or interpersonal therapy, respectively.  This last item is particularly significant in this case for two reasons: first, modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment; second, there was no evidence to suggest that treatment provided in a less restrictive treatment setting, such as an intensive outpatient program with community support groups, would have been insufficient at the time.  Thus, partial hospitalization program level of care was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Harvoni for the treatment of his hepatitis C.  Findings:  The physician reviewer found that according to the most recent guidelines issued, 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 non-cirrhotic genotype 1 patients should be treated with Harvoni.  For these reasons, the requested treatment with Harvoni is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a gene expression profiling test for evaluation of her medical condition.   Findings:  Two physician reviewers found that the service at issue was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is convincing scientific evidence that genetic testing of the uveal melanoma tumor can stratify the tumors into high and low risk for systemic metastasis. The test at issue is standard of care and most providers who treat patients with uveal melanoma routinely utilize this test for their patients. Moreover, this test determines how closely the patient is monitored and screened for metastasis. The testing information allows the reduction of frequency screening for those that are in the low risk category. Therefore, it is important to obtain the genetic information about the tumor when the opportunity is available, as it may not be possible to obtain later.  In the case of uveal melanoma there may only be one chance to obtain this genetic information from the tumor and it is typically in the beginning or until much later if there is metastasis. Thus, the testing at issue provides critical prognostic information that would not be available otherwise. As such, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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: One reviewer is board certified in ophthalmology and is actively practicing. Two reviewers are board certified in medical oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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).  Findings:  The physician reviewer found that Harvoni is medically necessary for treatment of the patients medical condition. The national guidelines that set the standard of care in managing and treating patients with HCV state the following 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 guidelines state that high priority for treatment owing to high risk for complications include patients with fibrosis of F2. Hence, based on the national guidelines the recommended regimens for treatment-experienced patients with HCV genotype 1 or 4 infection in the allograft, including those with compensated cirrhosis include daily fixed-dose combination of ledipasvir/sofosbuvir for 24 weeks who are ribavirin intolerant or ineligible. Based on the support per national guidelines and peer-reviewed literature, Harvoni is medically necessary in this clinical setting. 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 transcranial magnetic stimulation (TMS) therapy for treatment of her behavioral health condition. Findings:  The physician reviewer found that TMS is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  The American Psychiatric Association (APA) has endorsed TMS for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial. In this case, the patient presents with chronic affective illness. She has failed multiple adequate psychopharmaceutical trials. The documentation reveals that this patient has pursued, but not exhausted other standard therapies used to combat depression. However, considering the medical records, endorsement from the APA and the expanding peer-reviewed literature base, TMS represents a safe, appropriate treatment consistent with good medical practice. The therapy would be reasonably expected to improve the patients condition and prevent a more serious episode of illness. As such, the requested therapy is medically necessary for treatment of the patients behavioral health condition. 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 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 Viekira Pak for eight weeks for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to the most recent guidelines issued, all patients with chronic hepatitis C, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The guidelines also state that there are benefits in reduction of transmission from women to their children. Per the guidelines, Viekira Pak should be used for 12 weeks rather than eight. Moreover, there is a lack of medical studies for the treatment of Viekira Pak for eight weeks for patients with HCV genotype 1. For these reasons, the requested treatment with Viekira Pak for eight 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Bioness L-300 Foot Drop System for treatment of his medical condition.   Findings:  The physician reviewer found that the Bioness L-300 Foot Drop System is not medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient has not had a lengthy trial of a well fitted ankle-foot orthosis (AFO), custom made if necessary to improve compliance and comfort. An AFO is the first-line treatment for his condition and he has not exhausted the possibility of benefit from this type of device. In addition, researchers assessed the effects of a neuroprosthesis (NESS L300) designed to ameliorate foot drop on gait symmetry and rhythmicity during walking. They found that use of the NESS L300 makes gait more symmetric, reduces stride variability, and improves walking speed. In this case, these benefits were not seen in the patients brief trial. The Bioness device was objectively inferior to the AFO. All told, the requested services are not indicated for 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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: The parent of an enrollee has requested residential treatment center level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient required residential admission based on her noncompliance, rapid weight loss, and inability to be stabilized on an outpatient or partial hospital basis.  Subsequently, the patient was more cooperative and was not so overtly rebellious that her behavior could not have been managed at a lower level of care.  Her weight was more stable, and she was intermittently orthostatic.   All told, the submitted records support the medical necessity of eating disorder residential treatment center level of care initially, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested shoe lifts for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that Russell-Silver syndrome is a genetic syndrome characterized by intrauterine and postnatal growth retardation, short stature, craniofacial and body asymmetry, fifth finger clinodactyly, and congenital heart defects.  Leg length discrepancy is one of the main clinical features of this syndrome, and appropriate management at all levels is essential to the success of affected patients.  This patient has an almost 2 cm leg discrepancy, and according to the documentation submitted, may require limb equalization surgery at some point in the future.  However, at this time, he is able to participate in all appropriate activities with the aid of shoe lifts.  In order to facilitate functional progress and normalize his development and ambulation, shoe lifts were medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the equipment at issue was 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 pediatrics with sub-specialty certification in pediatric critical care 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 has requested an outpatient sleep study for the evaluation of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patient has had a diagnosis of sleep apnea.  The next step in his work-up is a CPAP titration study at a certified sleep medicine facility.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested outpatient sleep study is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested services are 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: 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. Findings:  The physician reviewer found that the proposed treatment regimen of Harvoni is medically necessary and is considered the standard of care for the treatment of patients with hepatitis C virus (HCV), genotype 1. Per the guidelines, all patients with chronic active HCV are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Further, a modeling study based on the Swiss HIV cohort also demonstrated that waiting to treat HCV at Metavir fibrosis stages F3 and F4 resulted in 2- and 5-times higher liver-related mortality respectively. Moreover, compared to those with HCV infection alone, persons with HCV/HIV co-infection have a higher rate of HCV persistence, faster progression to cirrhosis and end-stage liver disease, and higher HCV RNA levels. Persons co-infected with HCV/HIV also had lower responses to peginterferon and ribavirin than those with HCV infection alone, an observation largely explained by the higher baseline HCV RNA levels. Clinical trial data in HIV infected individuals with HCV genotype 1 or 4 infection have demonstrated the safety and efficacy of Harvoni. As such, the requested course of treatment with Harvoni 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 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: 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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology (ACR) statement on breast tomosynthesis has urged tomosynthesis be removed from an investigational category due to its utility in breast imaging. The advantage the technique offers is the ability of the provider to separate dense glandular tissue from mass/architectural distortion. There has been worldwide support for the tomosynthesis by providers due to an associated decrease in callbacks and increase in detection of small cancers.  For this reason, the use of tomosynthesis in this particular patient was likely of more benefit than if the mammographic views had been done with two-dimensional imaging only. 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 the Dexcom continuous glucose monitor for treatment of his medical condition.  The physician reviewer found that the Dexcom continuous glucose monitor is medically necessary for treatment of the patients medical condition. In this case, the patient has been managing his diabetes mellitus type 1 with the assistance of continuous glucose monitoring system, Dexcom. He has been adherent to real time self-management, hence his HbA1c is at target and he has not had harmful hypoglycemic events or severe hyperglycemia. That is exactly how continuous glucose monitoring must be used. In addition, the peer-reviewed literature cited above demonstrates continuous glucose monitor efficacy in improving diabetes control in a sustained way. In sum, the Dexcom continuous glucose monitor is medically necessary for this patient to continue his diabetes management and control at target levels without wide fluctuations and hypoglycemic events. 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 diabetes, metabolism and 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 has requested substance abuse intensive outpatient program 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 patients pattern of substance use was unlikely to change with outpatient and community resources alone.  The treatment team outlined a reasonable rationale supporting continued intensive outpatient program treatment.  The patient had made progress but had not yet consolidated the treatment gains necessary to succeed in the outpatient setting as she continued to experience craving and act impulsively in the context of a poorly developed sense of self, affective symptoms and anxiety.  The treatment provided was, and remains, reasonably expected to improve the patients condition while preventing a more serious episode of illness via relapse.  Further, the duration of care for a case of this complexity falls within typical community standards.  In sum, substance abuse intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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.