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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lyrica for treatment of his medical condition. Findings: The physician reviewer found that the patient presents with sciatic neuropathy from piriformis syndrome with neuropathic pain and has tried and failed first-line therapies for neuropathic pain. The use of Lyrica is supported in the peer-reviewed literature for the treatment of neuropathic pain. Robertson and colleagues noted that the use of Lyrica has shown favorable outcome for treatment of sciatica (sciatic neuropathy). In addition, Chaparro and colleagues noted that Lyrica has demonstrated benefit for various neuropathic pain conditions alone and in combination with other pharmacologic therapies. The systematic review and meta-analysis by Yu and colleagues noted that Lyrica demonstrated improvement in pain related to radiculopathy in sciatic distribution similar to gabapentin. Given the support in the peer-reviewed literature, Lyrica has been established as medically necessary for treatment of the 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 physician 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested right heart catheterization 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.  This patient was evaluated by multiple providers, and her providers felt her likelihood of having pulmonary hypertension was low.  Per the submitted documentation, all other cardiac testing was essentially negative. There is a lack of support for the requested right heart catheterization at this time, as she does not have progressive symptoms or a change in clinical status.  Standard medical practice supports repeat echocardiogram in this clinical setting.  All told, the requested right heart catheterization 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 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 treatment of his hepatitis C virus (HCV). Findings:  The physician reviewer found that According to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), treatment is recommended for all patients with chronic HCV infection, except those with short life expectancies owing to comorbid conditions. Because of the myriad of benefits associated with successful HCV treatment, clinicians should treat HCV-infected patients with antiviral therapy with the goal of achieving a sustained virologic response (SVR), preferably early in the course of their chronic HCV infection before the development of severe liver disease and other complications. Recent reports suggest that initiating therapy in patients with lower stage fibrosis may extend the benefits of SVR. In a long-term follow-up study, 820 patients with Metavir stage F0 or F1 fibrosis confirmed by biopsy were followed for up to 20 years. The 15-year survival rate was statistically significantly better for those who experienced an SVR than for those whose treatment had failed or for those who remained untreated. The study argues for consideration of earlier initiation of treatment (Jezequel, et al). Several other modeling studies suggest a greater mortality benefit if treatment is initiated at stages prior to F3 (vrehus, et al). Therefore, based on AASLD/IDSA guidelines, the requested Harvoni is medically necessary for treatment of the patients HCV. Final Result: The reviewer determined that the requested medication is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a FoundationOne genetic test for the evaluation of her metastatic breast cancer. Findings:  Two physician reviewers found that in this clinical setting, the procedure at issue was likely to be more beneficial in treatment of this patients metastatic breast cancer. This patient has exhausted treatment options but has maintained a sound performance status. Per the National Comprehensive Cancer Network (NCCN) Guidelines, the best management of any cancer patient is in a clinical trial. Specifically, the participation in clinical trials is especially encouraged. In addition, the use of genomic profiling such as with FoundationOne may help identify markers that will narrow the available clinical trials for this patient. Most institutions use this test to help guide decision making and eligibility for clinical trials. For these reasons, the FoundationOne genetic testing was likely to be more beneficial for treatment of this patients metastatic breast than any standard therapy. Final Result: Two reviewers determined that the 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: 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 internal medicine with sub-specialty certification in hematology and is actively practicing. One reviewer is board certified in internal medicine with sub-specialty certification in medical oncology and hematology 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Ampyra for treatment of her multiple sclerosis. Findings:  The physician reviewer found that the requested medication is medically supported in this clinical setting based upon the submitted documentation as well as evidenced based studies. Ampyra was approved based on primary outcomes in clinical trials that looked at an easily measured feature, walking speed. Studies of more broad health impact from Ampyra have noted improvements in patient-perceived physical and psychological health. A study by Fjeldstad and colleagues found significant improvements in gait, walking speed, distance, and balance were demonstrated by dalfampridine-ER re-initiation after a 10-day withdrawal period. In this patient, Ampyra was shown to improve the patients gait and coordination as documented by the patient and her provider. Since Ampyra has been shown to improve the patients gait and her coordination, its continued use is medically necessary for treatment of the patients multiple sclerosis.  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 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a prostatic urethral lift implant (Urolift) for treatment of his medical condition. Findings:  Two physician reviewers found that the submitted records fail to demonstrate the superior effectiveness of the requested services.  The Urolift may be a temporary solution to lower urinary tract symptoms and may be considered a bridge to more definitive therapy.  There is a need for double-blind, long-term studies to determine the long-term efficacy of this modality.  In this patients case, the requested Urolift procedure is not likely to be of greater benefit than other treatment alternatives. 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 urology 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 the enrollees medical condition. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  This is the specific clinical setting in which tomosynthesis has its greatest value.  The ability to separate overlapping structures enables visualization of an occult tumor which might otherwise have been missed.  Thus, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested BART genetic testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that at the present time, genetic testing is not applied universally but rather to patients who exhibit family histories that are suggestive of inherited predispositions (Frank et al). Genetic testing in this case was clearly indicated. BRCA 1 and BRCA 2 gene sequencing does not pick up all point mutations and gene rearrangement needs to be tested by other methods (Mazoyer). BRCA loss of function due to point mutation or rearrangement predisposes patients to increased risk for breast cancer and ovarian cancer. The detection methods are robust and are not experimental (Welcsh and King). Thus, testing for BRCA gene rearrangement (BART) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the service 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:  One reviewer is board certified in in obstetrics and gynecology with sub-specialty certification in gynecological oncology and is actively practicing. Two reviewers are board certified in medical oncology and hematology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a power wheelchair for treatment of her lower back pain and foot numbness and weakness.  Findings:  The physician reviewer found that there are no medical indications in the submitted records to establish the patient would be bed confined without a power mobility device. Per the patients documentation, there is no significant pertinent neurological or musculoskeletal impairments that would preclude ambulation with a cane or walker. There is also no evidence that the patient cannot walk without an assistive device. While the patient has poorly sized crutches, these issues can be addressed with new or adjusted crutches or a walker that is better suited for her physical frame. This could be followed with gait training, as recommended by physical therapy. There are also no significant pertinent neurological or musculoskeletal impairments that would preclude self-propulsion of an appropriately fitted manual wheelchair. Medical studies support the use of higher levels of physical activity rather than the lower levels of physical activity that a power mobility device would encourage (Hagen et al and Keyser et al). All told, the requested power wheelchair is not medically necessary in treatment of this patients medical condition.   Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 intensive outpatient program (IOP) services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that in this clinical setting, the treatment services provided to the patient were medically necessary. Per the records, her substance abuse was dominating daily functionality. Considering the presentation, an intensive outpatient (IOP) program was reasonably expected to improve the patients condition and prevent a more serious episode of illness. The level of care was safe, appropriate and consistent with accepted medical practice while the duration of care was consistent with community standards.  Finally, the American Psychiatric Publishing Textbook of Substance Abuse Treatment documents that patients who participate in IOP programs show improved functionality and decreased mortality is associated with individuals who complete the program. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients behavioral health 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested cervical artificial intervertebral disc surgery for treatment of his medical condition. Findings: Three physician reviewers found that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The evidence based medical literature does not support single-level artificial disc replacement in the setting of multilevel cervical degenerative disc disease. This patient presents with cervical pain radiating into the left arm with numbness and complaints of balance issues. Clinical exam findings evidenced decreased bilateral C5, C6, and C7 reflexes with no significant sensory or motor loss. Imaging demonstrated multilevel significant degenerative disc disease with cord compression at the C4-5 level, according to both the radiologist and treating physician. There is a lack of compelling rationale presented to support the proposed C4-5 artificial disc replacement over standard anterior cervical discectomy and fusion for this patient in the setting of multilevel cervical degenerative disc disease. Therefore, the requested cervical artificial intervertebral disc surgery is not likely to be more beneficial for treatment of the patients medical condition than any available standard treatment.  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 physician 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 positional magnetic resonance imaging (MRI) for evaluation of her medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  The peer-reviewed, evidence-based, medical literature does not support the use of positional (sitting) MRI for evaluation of coccydynia or coccyx fracture. This patient presents with chronic lower back pain in the coccyx area, with excruciating pain while sitting and significant functional limitation in sitting tolerance.  A sacral computed tomography (CT) scan was reportedly negative for fracture or dislocation. There is also documentation of a lumbar MRI with no discussion of sacral findings. There is no evidence that dynamic radiography has been performed. There is no orthopedic report of clinical findings relative to the coccyx. There is no compelling rationale presented to support the need for positional MRI in the absence of evidence based support and lacking clear and thorough documentation of previous imaging and radiographic tests and findings. Therefore, the requested positional MRI is not likely to be of greater benefit than other modalities for evaluating this patient.  Final Result: Three reviewers determined that the requested services are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested intravenous immune globulin for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  A recent review by Bayry and colleagues stated despite promising clinical trials, intravenous immunoglobulin (IVIG) therapy in relapsing-remitting multiple sclerosis (MS) has met with uncertainties that might be attributed to small patient cohorts, heterogeneity in the patients, dose of IVIG, or the duration and window of treatment. All told, the requested intravenous immune globulin treatment 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 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.