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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Repatha for treatment of his medical condition. Findings:  The physician reviewer found that based on the records provided, the patient has hyperlipidemia. However, there is a lack of documentation submitted for review demonstrating obstructive coronary disease (no angina and no ischemia on stress testing). In this clinical setting, incremental addition of a PCSK9 inhibitor such as Repatha is not medically necessary and not considered the standard of care in the medical community. There is no documentation that the patient has heterozygous familial hypercholesterolemia. Heterozygous familial hypercholesterolemia usually manifests by a combination of physical exam findings (arcus cornealis below the age of 45, tendon xanthomatas) and LDL- cholesterol levels that are at minimum above 150 mg/dl. None of the above is documented in the medical records provided. In addition, there is no evidence the patient has obstructive coronary vascular disease. PCSK9 inhibitors have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented obstructive coronary heart disease who require additional lowering of LDL-cholesterol. This patient does not fit any of those criteria. Also, current guidelines endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this setting. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Subsys 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.  This patient has chronic non-malignant pain.  The current standard of care for chronic pain is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsants and antidepressants considered adjunctive to this therapy. If there is poor response to conservative therapy, then interventional treatments should be considered. High-dose opioids are associated with a high risk of dependence and tolerance.  Researchers reported that high-dose and short-acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition.  Other researchers reported that prolonged use of high-dose, short-acting opiates might induce tolerance and abnormal pain sensitivity.  All told, Subsys 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections for treatment of her medical condition. Findings:  The physician reviewer found that Orthovisc is a high molecular weight hyaluronan. Most experts agree that its use is best in those patients with osteoarthritis (OA) of the knee who have not responded adequately to or tolerated acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) nor received significant relief from intraarticular glucocorticoids. In this case, the medical records submitted for review document failure of conservative therapy. The patient has received a previous steroid injection to the knee with no response. In addition, the documentations submitted for review demonstrates osteoarthritis of the knees. For the reasons provided, the medical necessity for Orthovisc injections has been established 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 internal medicine and allergy and immunology 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 inpatient mental health treatment services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that although dementia of the Alzheimers type is most common, Lewy body dementia may be more prevalent than previously recognized. Regardless of the particular type, dementia is a chronic and progressive disease complex that often demands treatment in specialized facilities in the later stages of the illness. Transient treatment in acute settings  is also necessary due to the myriad of biopsychosocial complexities associated with major neurocognitive disorders. Due to limited cognitive faculties and medical conditions, most notably insulin-dependent diabetes, this patient requires a locked memory care unit with medical services.  Retaining this patient in the acute setting until said placement can be arranged is safe, appropriate and consistent with good medical care as this patient poses an imminent threat to herself, and possibly others, in a medically unsupervised or custodial setting. Final Result: The reviewer determined that the services at issue were and 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 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:  The parent of an enrollee has requested Synagis for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that according to Jung `The morbidity caused by respiratory syncytial virus (RSV) infection in children with congenital heart disease (CHD) correlates with the severity of the underlying cardiac disease, represented by the degree of compromise of the baseline functional status in cardiopulmonary system, pulmonary flow/ventilation mechanics, degree of cyanosis, level of pulmonary hypertension and extent of ventilation/perfusion mismatch.`  This patient has complicated and severe congenital heart disease, placing her at continued risk of contracting severe RSV disease despite her age.  Despite not meeting American Academy of Pediatrics guidelines, because of the complexity of this patients congenital heart disease and the significant risk of morbidity and mortality with RSV infection, Synagis is medically necessary and appropriate for this patient for the duration of the RSV season.  Final Result:  The reviewer determined that the requested medication is medically necessary for the 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested the LINX Anti-Reflux procedure for the treatment of his medical condition.  Findings:  Three physician reviewers found that the LINX Reflux Management System has been approved for lower esophageal sphincter augmentation.  Eligible patients for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm.  Results from early studies are encouraging.  However, at this time, the data for the LINX procedure is from observational data and not from high-quality randomized controlled trials.  There is a lack of controlled data comparing the LINX procedure to a standard reflux operation, Nissen fundoplication.  All told, the LINX Anti-Reflux procedure is not likely to be more efficacious than other treatment options.  Final Result: Three 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 internal medicine with sub-specialty certification in gastroenterology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a positron emission tomography/computed tomography (PET/CT) full body scan every three months for evaluation of her medical condition.  Findings:  Two physician reviewers found that the medical records provided indicated that this patient had previously developed symptoms and widespread metastatic disease was detected.  She has had an excellent response to her chemotherapy, and her most recent PET/CT scans reveal no evidence of metabolically active disease.  Her routine CT scans, however, do reveal residual sclerotic changes.  Per the medical records, this patient continued to receive aggressive chemotherapy, which carries with it a significant risk of complications.  In this patients case, it is appropriate to continue the use of PET/CT scanning as this was the modality that initially demonstrated the metastatic disease.  All told, a PET/CT full body scan every three months is likely to be of greater benefit than other options for evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the American College of Radiology (ACR) statement on breast tomosynthesis has urged the technique be removed from the investigational category due to the advantages this new technique brings to radiologists in the interpretation of mammograms. The advantages the technique offers relates to the tomographic nature of tomosynthesis which helps radiologists differentiate dense glandular tissue from architectural distortion which in turn decreases callbacks and increases detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two-dimensional (2D) images was likely of more benefit to the patient than had the exam been done with 2D technique only. In sum, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:   All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 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. The guidelines recommend that treatment-naive genotype 1 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 infection regardless of fibrosis stage. For these reasons, Harvoni is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis adds to digital mammography, especially in cases of heterogeneous and extremely dense breast tissue.  This technique has resulted in decrease in callbacks and increase in detection of small cancers due to the ability of radiologists to separate dense glandular elements from underlying architectural distortion.  Thus, the addition of tomosynthesis to the usual two-dimensional images was likely of more benefit to this patient than had the examination been done with the two-dimensional technique alone.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested balloon sinuplasty for treatment of his medical condition. Findings:  Three physician reviewers found that according to the American Academy of Otolaryngology, Head and Neck Surgery guidelines, chronic rhinosinusitis is defined as a persistent inflammatory disorder of the paranasal sinuses with symptoms of persistent facial pain, discolored nasal discharge, and symptoms that are refractory to appropriate medical management including antibiotics, nasal anti-inflammatory medications and decongestant therapy. Additionally, CT scan imaging usually documents relatively extensive mucous membrane changes within the ethmoid, maxillary and other paranasal sinuses with blockage of the ostiomeatal complex. In this specific case, CT scan imaging did not show evidence of any blockage of the ostial complex. In addition, the CT scans performed documented very minimal evidence of any active sinus infection with only mucous membrane thickening within the maxillary sinuses, but the sinus ostial pathways remained open. Clinical indications for sinus surgery have not been met in this clinical scenario. Therefore, balloon sinuplasty is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition.  Credentials/Qualifications:   All three reviewers are board certified in otolaryngology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three 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.  As noted by a researcher, this technology has the  potential to change conventional mammographic screening and diagnostic imaging with possible improvements in cancer detection, decreased callbacks, and fewer false positive biopsies.  As in this patients case, 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.  Thus, breast tomosynthesis was likely to have been more effective than other modalities for evaluating this patient. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The spouse of an enrollee has requested gene testing (molecular profiling) for evaluation of his medical condition.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Identifying molecular markers helps identify available clinical trials and narrow the scope of where patients may be referred or to which trials the patient would be appropriate as we move to a more personalized style of oncology care.  Given the incurable nature of most metastatic colorectal cancers and the preference to be enrolled in a clinical trial if possible, molecular profiling was appropriate.  All told, genetic testing (molecular profiling) was likely to have been of greater benefit than other methods of evaluating this patient.  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 internal medicine with sub-specialty certification in medical oncology 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.