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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Norco for treatment of his hip and back pain. The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for Norco has not been established. Such narcotics are presently indicated for severe cancer pain in patients who are opioid tolerant and with a limited life expectancy. Additionally, the dose of Norco poses a risk for acetaminophen toxicity. The patient has non-malignant chronic pain, which will often worsen or recur as a result of opioid rebound. Ballantyne and Mao reported that prolonged use of high dose opiates might induce tolerance, abnormal pain sensitivity, and hormonal effects. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. For the reasons provided, the patients request for Norco is not medically necessary. 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 anesthesiology with sub-specialty certification in pain medicine 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 atovaquone (Mepron) for treatment of her Babesia infection.  The physician reviewer found that according to the documentation submitted for review, this patient is positive for Babesia duncani and not Babesia microti infection. Patients with Babesia microti infection present with acute infection with symptoms of fever, rigors, anemia and arthralgias. These patients may also have co-infection with Borrelia burgdorferi or Anaplasma. The standard treatment for Babesia microti infection is atovaquone 750 mg for seven days with azithromycin 600 mg daily for seven days. The patient has not shown PCR or smear positivity, which is usually present with Babesia microti infection. In addition, the patient has requested a higher than standard dose on a daily basis and for an extended period of time which is not the standard of care. This patient is positive for Babesia duncani which is treated with quinine, quinidine and clindamycin and not a single agent atovaquone. Based on the medical literature and clinical documentation provided, (atovaquone) Mepron 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 evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine 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 24-week course of Sovaldi and ribavirin for treatment of her hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medications in this clinical setting.  The American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines note that 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.  The initiation of treatment for patients with early-stage disease may help avoid untoward complications from advanced disease, including liver failure and extrahepatic complications of hepatitis C.  All told, the requested 24-week course of Sovaldi and ribavirin is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 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 12 weeks 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. Therefore, the requested Harvoni for 12 weeks is supported as medically necessary for treatment of this patients chronic 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 Victoza for treatment of the enrollees diabetes.   The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  This patient has uncontrolled diabetes.  He is already on basal insulin and requires post prandial control.  Per the medical records, he has been treated with Victoza in the past with good response.  The records indicate that the provider recently ordered laboratory testing to assess the patients current metabolic status as well as hemoglobin A1c level.  Although the results of this testing were not provided for review, the hemoglobin A1c level is not critical to determine the necessity of Victoza.  It is more important to control this patients diabetes to prevent complications.  In this patients case, the requested medication Victoza is medically indicated for this patient so that he can regain diabetes control.  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 endocrinology, diabetes 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 requested a 12-week course of Harvoni for treatment of his hepatitis C.  Findings:  Two physician reviewers found that per American Association for the Study of Liver Diseases and Infectious Diseases Society of America guidelines, patients with chronic active 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.  The goal of treatment is to reduce liver-related health adverse consequences, including end-stage liver disease and hepatocellular carcinoma.  Therefore, the requested 12-week course of Harvoni is medically indicated for the treatment of this patient.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested inpatient hospitalization level of care for treatment of the enrollees behavioral health conditions.   The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient denied suicidal ideation. Additionally, it appears that the suicidal ideation expressed on admission and during her stay was passive in nature.  She had no plan or intent.  Her depression and related suicidal ideation were at least partially related to her chronic pain.  She was not homicidal, and she was not psychotic.  The patient was not cognitively or functionally impaired.  She was cooperative and engaged in treatment.  Her mood and coping skills had improved, and she was tolerating her medications.  She had improved and the records do not indicate that she would decompensate at a lower level of care.  Thus, the patient did not require 24-hour nursing supervision on an inpatient unit and could have safely been treated at a lower level of care.  All told, inpatient hospitalization was not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue 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 psychiatry with sub-specialty certification in child and adolescent 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Sovaldi for treatment of her hepatitis C virus (HCV).  Findings:  Two physician reviewers found that Sovaldi (sofosbuvir) and ribavirin is medically necessary and is considered the standard of care for the treatment of the patients with HCV, genotype 3. In addition, treatment with Sovaldi is expected to be beneficial for this patient by potentially curing HCV infection and preventing further damage of the liver and progression of the disease process and development of cirrhosis and its potential complications. The combination therapy with Sovaldi and ribavirin has been approved by U.S. Food and Drug Administration (FDA). Therefore, the combination of sofosbuvir and ribavirin is medically necessary for this patient with HCV genotype 3. 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 an eight-week course of Harvoni for treatment of her hepatitis C (HCV).  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, 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.  The evidence supports an eight-week course of Harvoni for non-cirrhotic patients with hepatitis C, genotype 1 with a viral load less than 6,000,000 IU/mL.  All told, the requested eight-week course of Harvoni is medically indicated for the treatment of this patient.  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. 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 Harvoni for eight weeks for treatment of her hepatitis C virus (HCV).  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 as such, is expected to benefit nearly all chronically infected persons. Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. Therefore, Harvoni for eight weeks is medically necessary to prevent further progression of fibrosis due to ongoing HCV infection and prevent potential complications of advanced liver disease, long term. 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. 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 requested breast surgery for treatment of her bilateral ruptured silicone breast implants.  Findings:  The physician reviewer found that the medical literature reported that complications that arise from this surgery are well documented to include implant rupture and capsular contracture.  According to the medical literature It has become increasingly apparent in recent years that breast implant recipients experience a significant incidence of complications and a relatively high rate of reoperation.  In large-scale follow-up studies conducted by manufacturers, it was reported that by the end of 5 years, women undergoing augmentation with saline-filled implants had a 10 percent rate of significant (Baker grade 3 or 4) contracture. The medical literature reported that capsular contracture is the most common and severe complication associated with silicone breast implants. She is not documented to complain of significant pain or have evidence of implant infection. Based on the entirety of the medical record, the patient had original augmentation mammoplasty for aesthetic concerns, and experienced a known complication in which her implants were replaced. A ruptured silicone implants can be considered an abnormal, however there is no evidence that there was trauma, infection, tumors, disease, congenital defects, developmental abnormalities to suggest an etiology of the implant rupture. In addition, there is no evidence that the patient has a functional deficit related to her implants. There is no evidence that the initial surgery was performed for reconstructive reasons. The surgery was performed to correct previous aesthetic intervention.  This implies a baseline relatively normal appearance. Thus, the surgery performed was for returning to an improved appearance relative to normalcy. Therefore, the surgery at issue does not meet the reconstructive surgery criteria. Final Result: The reviewer determined that the surgery at issue was not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in plastic and reconstructive 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested inpatient psychiatric hospitalization for treatment of his chronic schizophrenia with acute exacerbation.   Findings:  The physician reviewer found that the patient remained delusional but denied suicidal and homicidal ideation, was eating well, was taking medications, and denied side effects from medication. The medical literature noted that the chief purpose of acute inpatient psychiatric hospitalization is safety. Moreover, the medical literature noted that studies have shown day hospital generally fosters outcomes similar if not identical to those of acute inpatient psychiatric hospitalization. The medical literature also showed there is substantial overlap in levels of severity between persons in residential versus acute psychiatric inpatient hospital care. Given this patients level of function, acute psychiatric inpatient hospital level of care was not medically necessary for this patient during the period of time in question.Final Result: The reviewer determined that the services at issue 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested vertebral axial decompression for treatment of his medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  This patient did not report leg pain per the submitted documentation.  The office notes indicate that the patients problem was mechanical and not neurological.  Therefore, the medical evidence does not support vertebral decompression given this patients diagnoses.  All told, the superior efficacy of vertebral axial decompression performed has not been established. Final Result: Two reviewers determined that the services at issue were 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: Reviewers 1, 2, and 3 are board certified in chiropractic care 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: 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 virus (HCV). 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. In this case, the patient has advanced stage disease and therefore, it is imperative and medically necessary to treat his HCV infection to potentially eradicate it and prevent further progression and decompensation of his liver disease. 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: Reviewer 1 is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Reviewers 2 and 3 are board certified 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.