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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested bariatric surgery (Lap-Band surgery) for treatment of her medical condition status post gastric bypass surgery with weight regain, reflux, and intermittent vomiting.  The physician reviewer found that although this patient presents with morbid obesity and has documentation of diabetes, the patient already had a prior laparoscopic Roux-en-Y gastric bypass procedure. While the requested procedure laparoscopic adjustable gastric band is considered a primary treatment for morbid obesity, it is not supported for patients when utilized as a salvage operation to be placed over a prior gastrojejunal anastomosis. There is a lack of evidence to support that this practice is safe, effective or results in any durable long-term weight loss. All told, the requested repeat bariatric surgery (Lap-Band surgery) is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested surgery 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 surgery with sub-specialty certification in bariatric 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition. Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The addition of breast tomosynthesis to the usual screening views has been widely accepted by radiologists due to the associated decreased callback rate and increased detection of smaller cancers.  This technique has proven especially valuable in patients with extremely dense tissue, as in this patients case.  All told, the addition of tomosynthesis to the usual screening protocol was likely to have been of greater benefit to the patient than digital mammography alone.  Therefore, the submitted documentation supports the superior efficacy of the breast tomosynthesis.  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 Sovaldi for 12 weeks for treatment of his hepatitis C virus. Findings:  The physician reviewer found that according to the joint guidelines from the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) 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 as such, is expected to benefit nearly all chronically infected persons. Per the AASLD/IDSA guidelines, daily sofosbuvir (Sovaldi) and weight-based ribavirin for 12 weeks is recommended for treatment-naive patients with hepatitis C genotype 2. As such, the requested treatment is medically necessary and is considered the standard of care for the treatment of the patients with hepatitis C genotype 2. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C virus.   Findings:  Two physician reviewers found that according to 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni as a Class I, Level A recommendation. 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. Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for eight weeks in this case. 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. In treatment naive genotype 1 patients, therapy is recommended 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.  Additionally, treatment of patients before they progress to cirrhosis is advantageous. Lower cure rate has been reported in patients with cirrhosis. Treating patients at an earlier stage of liver fibrosis results in significant improvement in life-years, specifically, treatment with Harvoni resulted in a 66% reduction of overall liver-disease-related complications when patients were treated at fibrosis score F2 versus F3F4, and 82% reduction in complications with treatment at F0F1. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni for 12 weeks is supported as medically necessary for treatment of this 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 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 Anser ADA testing and Prometheus Anser IFX testing for evaluation of her medical condition.  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the services at issue.  The patient was clinically doing well and had the gold-standard testing for disease activity; assessment and confirmation of mucosal healing.  Generally, low drug levels and presence of antibody correlate with loss of response. However, in this patient who was doing well she may need only a low level of anti-TNF (due to mild disease) to experience a benefit.  Navigating treatment based on the tests in question is not evidence-based.  All told, Anser ADA testing and Prometheus Anser IFX testing were not 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 not likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  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:   The parent of an enrollee has requested trauma services (CPT code 0681) for treatment of the enrollees medical condition.  The physician reviewer found that based upon the information provided for the review as well as the available evidence-based criteria, activation of the trauma team was medically necessary in this clinical setting. According to the Centers for Disease Control and Prevention (CDC) guidelines for field triage of injured patients, when evidence of a high energy impact exists, patients should be transported to a trauma center. CDC guidelines also note that evidence of such a high energy impact would include auto versus pedestrian/bicyclist thrown, run over, or with significant (>20 mph) impact. The mechanism of injury in this case justifies transport to a trauma center and trauma center activation because of the significant nature of the mechanism of injury. Further, the patient was appropriately triaged due to a concerning mechanism of injury. Moreover, the Pediatric Trauma Society guidelines for pediatric trauma team response state that a child can be called as a trauma stat at the discretion of the Emergency Medicine physician or Trauma Surgeon. As such, the trauma services (CPT code 0681) were medically necessary for treatment of the patients medical condition. 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 pediatrics and pediatric critical care and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested group speech therapy for treatment of the enrollees severe expressive and receptive language disorder.  The physician reviewer found that review of the submitted documentation and medical literature demonstrates the medical necessity of the requested services. The medical literature demonstrates that social skills groups are effective for social skills and communication skills for school age children with ASD. Group speech therapy often addresses social skills goals. In this case, the patients speech therapist recommends group speech therapy so the patient can effectively interact with peers, increasing her length of sentences and maintaining conversation. The school districts individualized education program (IEP) goals include social interaction goals, but focus primarily on communicating her knowledge of the academic material. Thus, the speech therapy goals in the school setting and by her private speech therapist differ. The school setting goals include communication of knowledge of academics, use of the speech device for greeting peers, reading at a second grade level and behavioral regulation goals. The speech therapy goals through the private speech therapist include increasing her length of sentences, maintaining conversational turn taking, and maintaining topic of speech. The private speech goals are more aimed at social communication goals due to the ASD. Therefore, based on the documentation submitted for review, group speech therapy is medically necessary in this clinical setting. 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 pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 risk for breast cancer. Three physician reviewers found that while there is a lack of long-term studies demonstrating increased survival rates correlated with the use of digital breast tomosynthesis as a part of screening mammography, recent data have shown great promise of the technique due to a decrease in repeated imaging and an increase in the detection of small cancers. The technique has been particularly useful in cases of dense breast tissue where the utility of standard digital mammography alone is limited. All told, the use of digital breast tomosynthesis in this patient was likely to have been more beneficial than standard screening mammography alone or any available standard modality. 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 Harvoni for eight weeks for treatment of her chronic hepatitis C virus genotype 1a.  Findings:  The physician reviewer found that according to the most recent 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 virus, regardless of fibrosis, should be treated except those with a life expectancy of less than 12 months due to non-liver-related comorbid conditions. In addition, treatment naive patients are recommended to be treated with Harvoni. These 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. Moreover, it is beneficial to treat patients with hepatitis C before they progress to F3 or F4 fibrosis. For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for treatment of this patients hepatitis C virus 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Supartz injections for treatment of his medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In their meta-analysis of 137 studies with 33,243 participants, Bannuru and colleagues concluded that hyaluronic acid was the best pharmacologic intervention for knee osteoarthritis.  Hyaluronic acid was found to be better than injected placebo or injected corticosteroids.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  The evidence-based peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  In this case, the patient has been diagnosed with severe osteoarthritis of the medial compartment of the left knee.  He has undergone two prior viscosupplementation series with positive results documented.  All told, the requested Supartz injections are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the enrollees medical condition.  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: Medical Necessity
Decision: Overturned Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:  An enrollee has requested a magnetic resonance imaging (MRI) scan of the abdomen.  Findings:  The physician reviewer found that this patient appears to have developed primary peritoneal cancer from a BRCA1 mutation.  This germline mutation raises the issue of radiation risk from diagnostic tests such CT scans. Large case control studies have shown that breast radiation from mammography should be avoided in BRCA mutation carriers specifically at a young age. Breast MRI is an alternative screening strategy for BRCA carriers.  The bulk of studies have focused on the radiation risks of breast tissue.  A computed tomography scan of the abdomen has 3-4 fold increased radiation exposure than a mammogram and involves more tissue.  Studies do suggest an association between radiation exposure and cancer occurrence in BRCA mutation carriers.  Thus, avoiding the exposure from multiple CT scans seems reasonable and a switch to abdominal MRI is medically appropriate in this patients case.  All told, the requested MRI scan of the abdomen is medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in medical 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:   An enrollee has requested Harvoni for eight weeks for treatment of her hepatitis C.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The proposed treatment is considered the standard of care for the treatment of the patients with hepatitis C, genotype 1 infection.  As per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, all patients with chronic active hepatitis C should be treated regardless of fibrosis score.  Per the guidelines, 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 eight 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 enrollees medical condition.  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.