Persius/hicric huggingface dataset:
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. Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is support in the medical literature for the use of breast tomosynthesis compared to the conventional mammogram due to improved cancer detection rate. Skaane and colleagues state The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Based on the medical literature cited above, the use of breast tomosynthesis 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for 12 weeks 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 proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  Per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic hepatitis C should be treated with antiviral therapy regardless of fibrosis score.  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.  All told, Harvoni for 12 weeks 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: An enrollee has requested rabeprazole for treatment of her medical condition.  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  As a drug class, proton pump inhibitors are indicated for healing erosive esophagitis and peptic ulcer disease, as well as to manage symptomatic gastroesophageal reflux disease and acid hypersecretory states.  Duration of action, side effects, and cost characterize proton pump inhibitor variations. No particular proton pump inhibitor can claim overall superiority, such that as a class proton pump inhibitors are interchangeable.  In this case, the available records do not support that the patients gastroesophageal reflux disease has advanced to Barretts esophagus, nor has she documented intolerance to specific proton pump inhibitors.  The available records do not indicate that she maximized treatment with step therapy.  All told, the requested medication rabeprazole 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested AmniSure laboratory testing for evaluation of her early labor.  Two physician reviewers found that the AmniSure testing was not likely to be more effective for this patient than any available standard therapies. The AmniSure test is used to aid in the detection of premature rupture of membranes (ROM) when the patient reports signs, symptoms or complaints suggestive of ROM. According to American Congress of Obstetricians and Gynecologists the diagnosis of ROM is typically confirmed by the visualization of amniotic fluid passing from the cervical canal and pooling in the vagina; a basic pH test of vaginal fluid; or arborization (ferning) of dried vaginal fluid. There is a lack of meta-analysis or randomized controlled trials demonstrating AmniSure is more beneficial than standard diagnostic methods. Therefore, AmniSure testing was not likely to be more beneficial than routine diagnostic methods.   Final Result: Two reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in obstetrics and gynecology with sub-specialty certification in maternal fetal medicine and is actively practicing.  Two reviewers are board certified in obstetrics and gynecology and are actively practicing. All three reviewers are experts  in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Victoza Pen injections, one injection daily for treatment of her type 2 diabetes.  The physician reviewer found that the submitted documentation fails to establish the medical necessity of the requested medication. Victoza and Bydureon are a members of the glucagon-like peptide 1 (GLP-1) analogues, a relatively new class of incretin-based therapies used in the treatment of type 2 diabetes that mimic the endogenous hormone GLP-1. This class of medications has shown significant improvements in glycemic control, progressive weight loss, low incidence of hypoglycemia and potential improvement of cardiovascular risk factors. Another important possible additional beneficial of these medications relates to potential improvements in beta cell function. All of the GLP-1 analogue therapies have been associated with significant glycemic control to date. In this case, because the patient is doing well on Victoza she will likely benefit from Bydureon as well. Given the reasons provided above, Victoza is not medically necessary for treatment of the patients medical condition. 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 endocrinology and metabolism 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 with a plan psychologist once per week and services with a plan psychiatrist once per month for treatment of his behavioral health conditions. The physician reviewer found that in this patients case, it is not medically necessary for him to see a plan psychologist at a frequency of once per week.  However, it is medically necessary that he received services from a plan psychologist.  This patient requires an updated treatment plan.  Input from a psychologist regarding formulation, level of care determination and the appropriateness of non-pharmacologic interventions is indicated in this case.  Thus, an initial comprehensive diagnostic psychological evaluation for purposes of clinical assessment and treatment planning is medically necessary.  The need for additional psychologist visits beyond the initial diagnostic evaluation will depend upon the exam findings.  Per the medical records, it is not medically necessary for the patient to see a plan psychiatrist at a frequency once per month.  However, it is medically necessary for him to see a plan psychiatrist.  The patients suicidality risk has been adequately assessed and has not been an issue of clinical concern during this episode of treatment.  The patient has been difficult to engage and has a history of not promptly following through with treatment recommendations.  However, from the psychiatric perspective, the patient has no significant safety concerns and has been stable on his current medication regimen for several months.  Frequent monitoring of response, as often as every other week, has been shown to improve results during acute phase treatment.  However, the method of monitoring can vary and may include office visits, phone calls, secure electronic correspondence or discussion with other professionals involved in the case such as case managers, nurses, health technicians and therapists.  Considering the patients chronicity and stability of the current medication regimen, quarterly office visits with monthly telephone calls in between appointments due to the prescription of a stimulant is medically indicated. Final Result: The reviewer determined that a portion of the requested services is 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   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 12 weeks for treatment of her hepatitis C.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  Harvoni has been shown to be effective in this clinical setting.  Based upon the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, immediate treatment with the highest priority is recommended for this patient with compensated cirrhosis.  All told, Harvoni for 12 weeks 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 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 Botox injections for treatment of her migraines. Three physician reviewers found that Botox is likely to be more beneficial for the treatment of medication refractory migraine headache. The patients migraine headaches have been refractory to all other conservative courses of care including numerous trials of both prophylactic and therapeutic agents. Further, the records document adequate trials of medications for appropriate lengths of time with their outcomes to support an indication for the requested Botox injections. Accordingly, the requested Botox injections are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested medication is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in internal medicine and neurology 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.  Three physician reviewers found that the submitted documentation supports the superior efficacy of the services at issue.  The addition of breast tomosynthesis to mammographic screening views has gained worldwide support among radiologists due to the unique tomographic capability of tomosynthesis.  Per the medical evidence, the addition of breast tomosynthesis has been associated with a decrease in callbacks and increased detection of small cancers.  All told, breast tomosynthesis was likely to be of greater benefit than other modalities.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak for treatment of her chronic hepatitis C virus genotype 1b.  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. In treatment-naive genotype 1b patients, therapy is recommended with Viekira Pak for 12 weeks. Given this recommendation, the requested Viekira Pak is medically necessary for treatment of this patients hepatitis C virus.   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: All three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: 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 her chronic hepatitis C virus genotype 1a.  Findings:  Two physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. The fixed dose combination ledipasvir-sofosbuvir (Harvoni) is FDA approved for the treatment of chronic hepatitis C genotype 1 in both treatment-naive and treatment-experienced patients. Given this support, the requested 12 week course of Harvoni is medically necessary for treatment of this patients hepatitis C virus.  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. 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 24 weeks of Sovaldi and ribavirin for treatment of his chronic hepatitis C virus genotype 3.   Findings:  Three physician reviewers found that as per the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines, all patients with chronic active hepatitis C are eligible for treatment and should be treated with U.S. Food and Drug Administration (FDA) approved antiviral therapy regardless of fibrosis score. Successful hepatitis C treatment results in sustained virologic response (SVR), which is tantamount to virologic cure, and is expected to benefit nearly all chronically infected patients. Consistent with the current guidelines, the requested 24 weeks of Sovaldi and ribavirin is medically necessary for treatment of this patients hepatitis C virus. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for eight weeks for treatment of his hepatitis C virus (HCV).  Findings:  Two physician reviewers found that denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The U.S. Food and Drug Administrations (FDA) label on the approved uses for Harvoni does include early stage disease. Thus, the recommendation is not to deny patients treatment if they have early stage disease but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from HCV.  Moreover, treatment delays may decrease the benefit of sustained virologic response (SVR). In a report by Jezequel and colleagues of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. Specifically, at 15 years, survival was 92% for those with an SVR versus 82% for treatment failures and 87% for those not treated. This was corroborated in many studies. Per American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) treatment guidelines, Harvoni is recommended for treatment-naive patients with HCV genotype 1 infection. Moreover, post-hoc analysis has revealed that non-cirrhotic HCV genotype 1 patients who are treatment naive and have a viral load of less than 6,000,000 IU/mL can be treated with an eight week course instead of 12 weeks and achieve similar cure rates. Therefore, Harvoni for eight weeks is medically necessary based on national guidelines.  Final Result: Two reviewers determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications:  One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her risk for breast cancer.  Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to standard two dimensional (2D) mammography. The addition of three dimensional (3D) breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue. Moreover, 3D breast tomosynthesis has been shown to improve patient outcomes in this clinical setting. Thus, 3D breast tomosynthesis 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 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.