Persius/hicric huggingface dataset:
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 virus.  Findings: The 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), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, Harvoni for 12 weeks 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otrexup for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Treatment with the prefilled form of injectable methotrexate is not medically necessary in this patient. There is no documentation to support why the regular form of injectable methotrexate is not acceptable, not efficacious or intolerable. On the basis of the available medical records, Otrexup 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 rheumatology 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 total knee arthroplasty for treatment of her medical condition. Findings: The physician reviewer found that the requested total knee arthroplasty has been established as medically necessary in this clinical setting. The patient has had appropriate conservative treatment including an arthroscopic debridement which was undertaken after informing the patient that it is not likely to have been successful. Based on the medical records, there is a lack of options available for this patient, other than total knee arthroplasty. Moreover, the proposed surgery is consistent with the standard of care for this patients medical condition (Cannada). Given the lack of alternative treatments available and that conservative care has been ineffective, the proposed total knee arthroplasty is medically necessary to improve the patients function of her knee. Based on the peer-reviewed literature and clinical documentation the requested total knee arthroplasty is clinically indicated for the treatment of the patients medical 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested tumor necrosis factor antagonists testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Some evidence exists that low serum levels of adalimumab and/or the presence of antibodies to adalimumab may play a role in primary or secondary response failures.  Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions.  In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment.  The reasons for therapeutic failures remain unclear.  Some evidence exists that low serum levels of adalimumab or the presence of adalimumab antibodies has an adverse effect on the clinical outcome of a patients response to treatment.  However, there are few well-controlled clinical trials to confirm that use of the testing in dispute leads to improved patient outcomes or quality of life as opposed to the standard method of treatment.  The clinical utility of measuring drug antibody concentrations has not been established, and it has not been established how patient management would change based on test results. Limited retrospective evidence describes changes in management after measurement to anti-drug antibodies, but does not compare these management changes to those made in the absence of anti-drug antibody measurement.  It has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established.  All told,  tumor necrosis factor antagonists testing was not likely to have been superior over other methods of evaluating this patient.   Final Result: Three reviewers determined that the services at issue were 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 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 a lumbar epidural steroid injection for treatment of his lumbar disc degeneration.  Findings:  The physician reviewer found that upon review of the submitted clinical documentation, the medical necessity of the requested lumbar spine injection has not been established. Per the medical literature, there is good (level II-2) evidence supporting the use of steroids for treatment of radiculopathy or radiculitis resulting from disc herniation and spinal stenosis. However, the submitted records do not provide confirmatory evidence of radicular symptoms. The patients pain is primarily in the low back with positive facet maneuvers, tenderness over the facets, negative straight leg raise test and no change in motor or sensory function. As such, evidence of radiculopathy or radiculitis is lacking in this case. In the absence of documented radiculopathy or radiculitis, the patient does not meet clinical indications for lumbar epidural steroid injection. Thus, the requested service is not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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 anesthesiology with sub-specialty certification in pain management 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 the medical literature supports the superior efficacy of the services at issue.  Per Skaane and colleagues, 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. As noted by Ciatto and colleagues, integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the medical evidence supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, breast tomosynthesis performed was likely to have been of greater benefit than other modalities for evaluating this patient.  Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for the evaluation of her medical condition.  Findings:  Two physician reviewers found that the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone (Ciatto, et al). In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Given the support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, 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:   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: Upheld 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 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.  However, in this patients case, there were no problems to be resolved.  The patient did not have dense breasts, a mass, palpable lumps, or suspicious calcifications.  Breast tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when multiple prior mammograms are available for comparison and do not demonstrate any interval change.  Thus, breast tomosynthesis was not likely to have been more effective than other methods of evaluating this patient.   Final Result: Two reviewers determined that the services at issue were 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 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 Sovaldi and Daklinza for treatment of her hepatitis C virus. Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to non-liver-related conditions. In treatment-naive genotype 3 patients (regardless of interferon eligibility), therapy is recommended with Sovaldi and Daklinza for 12 weeks. This is based on the ALLY-3 study, which showed a cure rate of 97% (Nelson, et al; Hezode, et al). Delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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 finasteride, estradiol valerate and spironolactone for treatment of her gender dysphoria. Findings:  The physician reviewer found that review of the submitted clinical documentation support the medical necessity of the requested medications. The requested dosages of finasteride, estradiol valerate and spironolactone are consistent with Endocrine Society guidelines for the treatment of transgender females. Estrogen (estradiol valerate) can be given orally, transdermally or parenterally (IM). Each has its risks and benefits. Measurement of serum estradiol levels is used to monitor estrogen therapy in all forms. The requested estradiol valerate is reasonable and consistent with Endocrine Society Guidelines for the treatment of transgender females. As such, the requested dosage of estradiol valerate is medically necessary for this patient. Spironolactone is an antihypertensive agent but also directly inhibits testosterone secretion and androgen binding to the androgen receptor. Thus, it is an effective anti-androgen and allows estrogen to have its fullest effect. The requested spironolactone is clinically appropriate and medically necessary in the patients care. Finasteride (a 5-alpha reductase inhibitor) blocks the conversion of testosterone to the more active agent, 5-alpha-dihydrotestosterone. These medications have beneficial effects on scalp hair loss, body hair growth, sebaceous glands and skin consistency. As such, the requested dose of finasteride is medically appropriate and necessary in this case.   Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an oxygen concentrator for treatment of his heart condition.   Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  The patients oxygen saturation on room air was normal. The lung volumes, flow rates and diffusion capacity were normal.  There is no documentation of hypoxia. Assuming significant heart disease, there is no documentation of oxygen saturation on room air of 89% or lower. Dyspnea on exertion is not an indication for oxygen therapy.  All told, the requested oxygen concentrator is not medically indicated for the treatment of this patient.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 internal medicine with sub-specialty certification in pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested proton beam radiation therapy (PBRT) for treatment of his medical condition. Findings: Three physician reviewers found that proton beam radiation therapy has a role in the treatment of some cancer patients. However, there is concern about physical uncertainties about proton depth dose delivery which may make the actual radiation deposition in tissue less conformal than it may appear based upon the treatment plan. Also, the depth of proton delivery is more susceptible to changes in tissue density. There is a lack of consensus guidelines or medical literature that supports the use of proton therapy for the palliative treatment of bone metastases. While re-irradiation is a possible indication of proton therapy, it must be demonstrated or plausible that proton therapy would result in a better dose distribution to allow normal tissue not to exceed the cumulative tolerance dose of nearby normal tissue. This has not been demonstrated in this case. Generally conventional three-dimensional conformal radiation can adequately spare normal tissue even when accounting for prior radiation, particularly in this case where the dose is likely palliative. Moreover, the case records do not adequately document what normal tissue is better spared with proton therapy. As such, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any standard treatments.Final Result: Three reviewers determined that the 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 radiation oncology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting.  The patient had a concerning history which dominated multiple functional domains.  The patient had been unable to achieve any meaningful sustained sobriety in an extended period of time.  Further, the patient had significant psychiatric comorbidity in the presence of acute psychosocial stressors.  Based on the medical records, discharge to a less restrictive setting would have been premature and resulted in undue morbidity, prompt relapse and re-admission. The patient was noted to be gaining insight and motivation for improvement, but still struggling with dysphoria, self-defeating behavioral urges and negative self-talk.  The records demonstrate that the patient had not consolidated the treatment gains necessary to success in a less restrictive setting.  The services provided during the timeframe at issue were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, residential treatment services were medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in psychiatry 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.