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

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for the medication, Harvoni 90-400mg, for 12 weeks. The enrollee was diagnosed 15 years prior with chronic hepatitis C virus (HCV); genotype 1a and is treatment naive. He also has a history of throat cancer and chronic myeloid leukemia. Laboratory results show a hepatitis viral load of 2,040,000 IU/mL. An ultrasound performed revealed a medial liver elastography of 4.6 kPa, corresponding to a METAVIR score of F0-1. Anti-viral resistance testing was done. This enrollee is Caucasian with a non-cirrhotic, chronic Hepatitis C genotype 1a infection. He is not subject to a short life expectancy that cannot be remediated with HCV treatment. According to current clinical guidelines and literature, Ledipasvir/Sofosbuvir (Harvoni) is a highly effective and safe treatment option for this enrollee. A clinical trial shows enrollees with HCV genotype 1 (GT1) who were treated with Harvoni achieved a sustained viral load (SVR), known as the treatment goal over 97%. However, considering the enrollees viral load is less than six million IU/ml, current literature supports Harvoni for eight weeks duration rather than 12 weeks duration. There is growing evidence that supports the comparable effectiveness of shorter treatment duration, eight weeks compared to the longer treatment duration, 12 weeks in terms of achieving the same sustained viral response (SVR) and treatment. Based on current literature on subgroup differences and response to treatment duration, medical guidelines for the treatment of HCV recommend eight weeks treatment of Harvoni be used for enrollees who are non-black, HIV-negative and have an HCV RNA level less than six million IU/ml. Based on literature, eight weeks treatment rather than 12 weeks of Harvoni is medically necessary for this enrollee. Final Result: The reviewer determined that the requested service is partially medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee requested reimbursement for care at a wilderness program. The enrollee was admitted to a wilderness program to which she was admitted for severe depression and a suicide attempt. She regularly used marijuana and alcohol, as well as occasional cocaine. She reported feeling isolated and not connected with herself or with her friends. The enrollee became aware that she was not in a healthy place and requested treatment from her family who helped her get to a wilderness program. Throughout her time at the wilderness program, she developed healthy coping skills, communication skills, problem solving skills and awareness. She participated in individual and group therapy, as well as organic gardening milieu. Treatment for substance abuse included individual sessions and group sessions, through which she identified triggers to her use. Recent criteria emphasize the availability of treatment for co-occurring mental disorders and medical conditions in conjunction with substance use disorder (SUD) care, because higher rates of these conditions are seen in enrollees with SUD compared with the general population. The study also showed that, compared to residential and intensive outpatient programs, outpatient programs were more likely to provide dual-diagnosis services, which correlates with this enrollees dual diagnoses of mental disorders and substance abuse. Wilderness therapy includes interventions that may not be available in a traditional outpatient weekly therapy format. However, the literature notes additional studies are needed to gain a better understanding of the foundations and components of wilderness therapy. As well, the quality of the programs is variable. Literature support for wilderness therapy program (also known as adventure therapy) is weak. Due to the lack of uniformity, framework, and clarity on the therapeutic process and treatment outcomes of these programs, studies in support for these programs efficacy and safety for the treatment of psychiatric illness among youths are not substantiated. As a result, there is insufficient literature evidence and guidance to determine who may or may not benefit from wilderness therapy.Final Result: Three of the three reviewers determined that the requested services were not likely to be more beneficial than any available standard therapy for treatment of the enrollees medical condition. Credentials/Qualifications: Three reviewers are board certified in Psychiatry and Child & Adolescent 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for blood work. The American College of Obstetrics and Gynecology (ACOG) discussed the use of tumor markers in the evaluation of an adnexal mass. The ACOG publication did not specifically add or address human epididymis protein 4 (HE4) in the recommendations for management and treatment. Evaluation of the symptomatic patient includes physical examination and may include transvaginal ultrasonography and measurement of levels of the serum tumor marker CA125. According to ACOG, combining CA125 with other markers in tumor marker panels may increase sensitivity by 5-10%, but with low specificity. In addition, prospective, large population-based studies have not demonstrated that tumor marker panels improve early detection and survival rates. Moreover, tumor markers like CA125 and HE4 are not useful to determine if an adnexal mass is malignant, or if a patient requires surgery to remove the mass. Thus, the blood work was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found the blood work was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the blood work  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 upheld. Credentials/Qualifications: Physician reviewers 1, 2 and 3 are board certified in obstetrics and gynecology 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 authorization and coverage for proton beam radiation therapy. Findings:  The physician reviewer found that the requested services were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.An evidence based study of proton beam therapy did not endorse the routine use of proton therapy in the treatment of breast cancer. In addition, consensus group guidelines do not support the use of proton therapy in this setting. In the vast majority of cases, intensity modulated radiation or 3D conformal techniques with photons is able to achieve an acceptable cardiac and lung dose. Also, there is no level I evidence to support the use of proton therapy for the treatment of breast cancer.In this case, the provider notes that comparative planning was performed. Due to image quality in the providers letter, however, the difference in mean heart dose between the photon and proton plans could not be distinguished. Therefore, there is insufficient data submitted that suggests that treatment with proton techniques will be able to improve sparing of the skin, heart, and/or lungs compared to standard intensity modulated breast radiation with photon techniques. Furthermore, as noted above, consensus group guidelines do not support the use of proton therapy in this setting, and there is no level I evidence to support the use of proton therapy for the treatment of breast cancer. Under these circumstances, the requested proton beam radiation therapy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services were 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 radiation oncology 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 patient has requested authorization and coverage for transcranial magnetic stimulation (TMS) services.Findings:  The physician reviewer found that Richieri and colleagues concluded that, maintenance TMS was associated with a significantly lower relapse rate in patients with pharmacoresistant depression in routine practice among responders. Leggett and colleagues noted that the current data suggests repetitive TMS (rTMS) for adults with treatment resistant depression is approximately twice as effective as a sham procedure, although the optimal rTMS protocol remains unclear. The medical literature has not clearly defined the number of TMS sessions for successful maintenance of depression symptom resolution. Patients respond differently to TMS, thus the number of sessions needs to be considered on a clinical instead of a numerical basis. Some patients require more than 30 treatments to successfully resolve their symptoms. The clinical information indicates that this patient presents with pharmacoresistant depression. She has received TMS on numerous occasions since 2016. The progress notes report that she has made consistent progress with TMS on each treatment course. Given the support in the medical literature, the TMS services that she has received were and are medically necessary for 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for combination therapy with Botox and Aimovig. The enrollee has a history of migraines and was referred to a neurologist for evaluation of chronic migraines. She had been on several preventative medications and failed. She had been receiving botox injections to treat her migraines and headache frequency was decreased after the injections. However, she had not had injections for the previous six months and her headache frequency had increased again. The enrollee received a Botox injection and Aimovig with her first dose of Aimovig resulting in a reduction in headache frequency. She received another Botox injection during the visit and was advised to continue Aimovig. A subsequent visit indicated the current combination of Botox and Aimovig had resulted in diminished headaches, from nearly daily to only six to eight per month. In addition, they were less severe, of shorter duration, and responded better to Frova in that only one dose managed the headache and there was no rebound. To date, current research on Aimovig (Erenumab) is limited to monotherapy (use of a single drug), prophylactic (preventative) treatment for chronic migraine. When the use of Aimovig (Erenumab) was approved for chronic migraine prophylaxis, the decision was based on three trial studies that supported the efficacy and safety of the drug as a monotherapy, and not as a combination therapy with other prophylactic regimens, such as Botox. Rather, according to a research review of multiple studies conducted for Aimovig (Erenumab), these studies specifically excluded individuals who recently had a Botox injection, within four months of screening/baseline, from the study participation. Thus, while there is some literature speculation on the possible combined effect of Aimovig (Erenumab) and Botox on targeting and stabilizing the inflammatory marker that is elevated in enrollees with chronic migraine, there have been no actual studies conducted to support the efficacy and safety of this combination (Aimovig and Botox) therapy.Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. 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 similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Tecfidera 240 mg. The current medical evidence supports the requested medication in this clinical setting. Tecfidera has been approved by the U.S. Food and Drug Administration for the treatment of relapsing-remitting multiple sclerosis. The mechanism of action of Tecfidera is different than Gilenya, Glatopa and glatiramer. The relative relapse reduction rate of Gilenya and Tecfidera is nearly equal. The relapse reduction rate of Tecfidera is better than Glatopa and glatiramer. Per the records, this patient is needle phobic, and she does not desire to pursue treatment with Gilenya due to risk of unpredictable progressive multifocal leukoencephalopathy. Selecting a medication that the patient finds more tolerable is likely to increase compliance. Therefore, Tecfidera 240 mg is medically necessary 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for psychiatric residential treatment center (RTC) services. The submitted documentation supports that psychiatric RTC services for the period in dispute were medically necessary. The submitted records reflect that the patient was not performing activities of daily living and she continued to have suicidal ideation. She did not have any delusions or hallucinations, but showed an appropriate affect in a depressed mood. The patient was cooperative with care, was actively involved in her treatment, and followed through with assignments. The patient had a composite score of 21-26 for the period of treatment in dispute. This correlates with treatment in a residential treatment facility. Therefore, psychiatric RTC services provided during the period in dispute were medically necessary for treatment of the patient. Regarding the recommended prospective ninety (90) days of continuous psychiatric residential treatment center services, the patient has a composite score of 19, which correlates with intensive outpatient treatment. However, given the significant score of 4 on the risk of harm, the American Association of Community Psychiatrists Level of Care Utilization System strongly recommends a medically managed or monitored residential setting. Thus, 90 days of continuous psychiatric RTC services are medically necessary for the treatment of this patient. Final Result: The reviewer determined that the services in issue were medically necessary for treatment of the patients medical condition. The reviewer also determined that the requested services going forward 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for intravenous immune globulin therapy.Findings:  Two out of three physician reviewers found that in this patients case, the records document anti-sulfatide polyneuropathy. Enrollee has severe pain, functional limitations, gastrointestinal symptoms and spasticity. Given the overall clinical picture and the possibility of an underlying autoimmune etiology, provider has recommended intravenous immune globulin therapy. There is medical evidence which supports immunomodulation in the form of intravenous immune globulin therapy for patients with an autoimmune neuropathy. Without intervention, this condition can progress and may result in significant disability. Therefore, intravenous immune globulin therapy is likely to be of greater benefit than other treatment options. Final Result: The reviewers determined that the requested medication is 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: Physician reviewers 1, 2 and 3 are board certified in neurology 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 has requested authorization and coverage for Humira injections 40 mg weekly. Humira has demonstrated efficacy for induction and maintenance of remission in patients with moderate to severe Crohns disease. However, more than one third of patients do not respond to induction therapy and many patients lose response over time, sometimes resulting in disease exacerbation. Optimization of therapies, or switch to other anti-TNF-a, are currently the best studied strategies in case of loss of response, and can be successful in 40-60% of patients who lose response (Danese, et al.). The ULTRA 2 trial showed that, escalation to weekly adalimumab dosing demonstrated clinical benefits for patients who lost response to therapy and may be beneficial for patients not initially responding to induction therapy (Wolf, et al.). The authors noted that no new safety risks were identified with weekly dosing. This patient has inflammation on colonoscopy despite treatment with Humira 40 mg every other week. Her provider has recommended a more frequent dosing schedule to every week, which is consistent with the current medical literature and guidelines. Accordingly, the Humira injections 40 mg weekly are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Findings:  Three physician reviewers found Humira injections 40 mg weekly are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested medication dosage is 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: Physician reviewers 1, 2 and 3 are board certified in internal medicine with subspecialty 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/ Case Summary:  The enrollee is requesting authorization and coverage for Cologuard testing. A gastroenterology note indicates the enrollee had an acute episode of gastroenteritis. Her physician explained screening options available, indicating the most accurate test is colonoscopy. Other options presented were fecal immunochemical test (FIT) screen, Cologuard, CT colonoscopy and colonoscopy.  Findings:  The physician reviewer found that guidelines for colorectal cancer screening indicate patients fifty years or older with no history of predisposing conditions or family history for colorectal cancer may be screened using colonoscopy, stool-based testing, immunochemical-based testing or DNA-based testing; flexible sigmoidoscopy, or computerized tomography (CT) colonography. Cologuard should be used in adults aged fifty older who are at average risk for colorectal cancer.  This patient is at average risk for colon cancer.  She does not meet the age criteria for the use of Cologuard testing.  Final Result: The reviewer determined that the requested service is not medically necessary for the treatment of the enrollees medical condition. Credentials/Qualifications: The physician 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 similar medical condition.