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

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging of the lumbar spine for evaluation of the enrollees back pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  In the setting of low back pain in which the patient is a candidate for surgery or other intervention, magnetic resonance imaging is the most important study.  In general, plain x-rays are often of very limited value.  Plain x-rays serve to evaluate the patient for significant structural abnormalities, such as fractures, malalignments and congenital anomalies.  However, plain x-rays are generally not beneficial for evaluating a patient for a cause for radiculopathy.  Patients can have significant disc herniations with normal plain x-rays.  Conversely, patients with significant degenerative changes in the lumbar spine may not have significant disc encroachment.  In this patients case, he has had a long course of conservative therapy.  Prior attempts at conservative therapy have included lumbar facet blocks, physical therapy and home exercise regimens.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested magnetic resonance imaging of the lumbar spine is medically indicated for the treatment of this patient.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 diagnostic radiology 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewer 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 the enrollees hepatitis C virus. Findings: The physician 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, in treatment-naive genotype 3 patients, Sovaldi and Daklinza for 12 weeks is a recommended regimen. This is based on the ALLY-3 trial showing a 97% cure rate in this population (Nelson, et al). Furthermore, delay in treatment may result in decreased survival (Jezequel, et al). For these reasons, hepatitis C treatment is needed, and Sovaldi with Daklinza for 12 weeks is supported as 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 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 reimbursement for venous blockage repair with stent placement.  Findings:  Two physician reviewers found that the patient has a history of left symptomatic lower extremity iliac deep vein thrombosis (DVT) during pregnancy. At that time an inferior vena cava (IVC) filter was deployed to prevent embolic disease. An iliofemoral thrombolysis was performed in the left iliac deep vein for DVT.  The records indicated that this procedure was effective.  During the imaging for her IVC filter retrieval, a narrow vein and multiple collaterals were identified suggesting venous stenosis and a possibility of May-Thurner syndrome anatomy with residual scarring from DVT.  The patients veins were opened but stenosed and no acute DVT.  Angioplasty was performed with documented failure due to recoil, so a stent was placed. The procedure at issue was likely to be more effective than other options for the treatment of this patients medical condition.  The current medical literature supports placement of iliac vein stents as effective and a safe approach for patients with post-thrombotic syndrome and non-thrombotic iliac vein lesions with a low incidence of perioperative complications and acceptable long-term patency. The current medical literature indicates that angioplasty has been effective for treatment of May-Thurner syndrome. This patients clinical records noted venous stenosis and a likelihood of May-Thurner syndrome.Final Result: Two reviewers determined that the procedure at issue was 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 vascular surgery 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 reimbursement for chemotherapy services for treatment of the enrollees hairy cell leukemia.  Findings:  The physician reviewer found that there is sufficient support in the evidence-based literature for the services at issue in this clinical setting. Hairy cell leukemia is a rare B-lymphocyte leukemia with an especially high rate of effective treatment. The optimal initial treatment of this disease is with the use of one of two purine analogs (pentostatin and cladribine). Cladribine is generally preferred, and a seven day of infusion of this drug will yield a complete remission rate of 91%. Approximately 16% of those who go into complete remission will experience a relapse.  The standard protocol in this clinical setting is re-treatment of such patients who relapse with cladribine again. Thus the treatment of this patient with cladribine, which is best given by a seven day inpatient infusion, was medically necessary. Final Result: The reviewer determined that the requested services 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 25 hours per week of individual therapy in an intensive outpatient program (IOP) and equine assisted psychotherapy for treatment of the enrollees post-traumatic stress disorder (PTSD), military sexual trauma, and chronic depression. Findings:  The physician reviewer found that based on the review of the available records, it has been noted that the patient has PTSD, military sexual trauma, and chronic depression. She has been undergoing treatment in the form of psychotherapy and medication management. The records do not specify the number of sessions of outpatient psychotherapy completed or evidence of objective functional improvement with the same. The documentation does not justify the clinical need for a higher level of care at this time as the records do not provide information regarding details of past treatment failures. Further, there is a lack of evidence that the patients psychosocial functioning has become impaired by moderate or severe symptoms of a mental health condition, and treatment cannot be adequately managed in a lower level of care. The request for authorization and coverage for 25 hours per week of individual therapy in an IOP and equine assisted psychotherapy is not medically necessary for treatment of this patients medical condition. Final Result: The reviewer determined that the requested services are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  Findings: Three physician reviewers found that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has a residual mass, and tomosynthesis has been shown to better delineate and characterize a mass. This has been previously biopsied, and the pathological findings were sufficiently convincing to allow the residual mass to be left in place. Tomosynthesis better delineates the margins. Furthermore, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the diagnostic procedure at issue was 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.Final Result: Two reviewers determined that the service at issue was 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 physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers 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 the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment.  Per the guidelines, treatment-naive genotype 1 patients should be treated with Harvoni.  Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks.  These guideline recommendations are based on multiple randomized clinical trials.  All told, Harvoni for eight weeks is medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested medication regimen 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 office balloon sinuplasty (frontal, maxillary, and sphenoid) for treatment of the enrollees chronic sinusitis.  Findings: Two physician reviewers found that while sinus ostial dilation with balloon sinuplasty is an appropriate therapeutic option for some patients with chronic sinusitis, the criteria have not been met in this patient. The indication for balloon sinuplasty is chronic sinusitis refractory to maximal medical treatment. The American Academy of Otolaryngology Head and Neck Surgery (AAOHNS) defines chronic rhinosinusitis as a clinical disorder characterized by inflammation of the mucosa of the nose and paranasal sinuses with associated signs and symptoms of 12 week consecutive duration. Chronic rhinosinusitis is characterized by two or more symptoms, including nasal obstruction or nasal discharge (anterior/posterior nasal drip), with or without facial pain/pressure and reduction or loss of smell with endoscopic evidence of mucopurulence, edema, polyps, and/or CT presence of mucosal thickening or air fluid levels in the sinuses. Chronic rhinosinusitis was not documented in this patient. There is a lack of documentation of chronology of disease, symptoms and treatment. There was no documentation of 12 weeks of consecutive symptoms. The patient reported five to six infections per year. However, there is no documentation that he was treated with maximal medical therapy prior to the CT scan. Moreover, there is no documentation of findings on nasal endoscopy consistent with sinus disease. All told, the records provided for review do not demonstrate that the requested in office balloon sinuplasty (frontal, maxillary, and sphenoid) is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the requested 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 otolaryngology 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 authorization and coverage for Harvoni for 12 weeks. Findings:  The physician 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, non-cirrhotic genotype 1 patients who have failed peg-interferon and ribavirin 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. 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 reimbursement for the cystoscopy chemodenervation with botulinum toxin. Findings:  Two physician reviewers found that the procedure at issue was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Patients with neurogenic bladder can have significant detrusor overactivity leading to urinary incontinence. Anticholinergic medications are first-line therapy, and patients refractory to medications can be managed by minimally invasive therapies such as Botox injection and sacral neuromodulation. Botox injections have been shown to improve compliance and reduce detrusor overactivity in patients with neurogenic bladder refractory to medical therapy, such as in this case. According to the European Association Urology (EAU) guidelines Botulinum toxin injection in the detrusor is the most effective minimally invasive treatment to reduce detrusor overactivity. Final Result: Two reviewers determined that the procedure at issue was 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 urology and are actively practicing. The reviewer 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 digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.  In this case, the patient has breasts that have been described as extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Similarly, with the questionable history of an axillary mass, a tomosynthesis is especially valuable considering the density of her breasts. For the reasons provided, the digital 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 diagnostic procedure at issue was 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 physician reviewers are board certified in diagnostic radiology 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.