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

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuous electroencephalogram (EEG) monitoring, magnetic resonance imaging (MRI) scan with sedation, computed tomography (CT) scan, and transfer to Kaiser Permanente Downey Medical Center for treatment of the enrollees medical condition. Findings: The physician reviewer found that the requested services have not been established as medically necessary for treatment of the patients medical condition. The patient has been found neurologically stable for discharge. There is a lack of clinical evidence demonstrating that the patient requires further inpatient treatment or monitoring for seizures. The seizure-like activity noted during the patients inpatient stay was not epileptic in nature. The patient is stable for treatment on an outpatient basis. Inpatient EEG monitoring did not show epileptiform activity. Based on the review of the records it is not medically necessary for the patient to receive continuous EEG monitoring, CT scan, and MRI scan with sedation, and transfer to Kaiser Downey Medical Center. All told, the requested services are not medically necessary for treatment of the 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 neurology 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 the enrollees risk for breast cancer. Findings: Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the patient has breasts that have been described as being extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically 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. While tomosynthesis is a valuable tool in delineating occult masses in dense breasts, there is still an advantage to sonography in detecting cystic structures. Thus, in this clinical setting, the use of 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 reimbursement for breast tomosynthesis. Findings:  Three physician reviewers found that 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 the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies.  In this patients case, the report noted dense breast tissue.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: The 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: Reviewers 1, 2, and 3 are board certified in diagnostic radiology and is actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an EasyStand Evolv Stander (sit-to-stand stander) for treatment of her medical condition.  Findings:  Three physician reviewers found that the requested equipment is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The medical literature on standing frames to address health and functional issues in the setting of neurological disorders is sparse and consists of preliminary studies with inconclusive results. There is a lack of high-grade evidence to support that use of this type of passive standing device significantly improves functional outcomes over active exercise. Newman and Barker evaluated whether supported standing can affect lower limb muscle length, spasticity, bone mineral density or the function of adults with upper motor neurone disorders. The authors concluded Supported standing can prevent small losses of ankle mobility but the clinical importance of these effects is uncertain. Given the lack of adequate evidence in the medical literature demonstrating the stander provides clinically significant benefits with respect to health outcomes in this clinical setting, the requested equipment 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 equipment is 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 reviewers are board certified in physical medicine and rehabilitation 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 the enrollees medical condition.  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. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic genotype 1a patients who have failed treatment with 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 (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni is medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical placement of an Enterra device to the stomach for treatment of her gastroparesis secondary to diabetes. Findings:  The physician reviewer found that in the medical literature, a meta-analysis of 13 studies reported significant benefits following gastric electrical stimulator placement in terms of symptoms, nausea, and vomiting (OGrady, et al). A recent meta-analysis showed similar results, but identified diabetic gastroparesis patients as the most responsive to gastric electrical stimulator, while the idiopathic gastroparesis and postsurgical gastroparesis subgroups were less responsive (Chu, et al). Further, the American College of Gastroenterology guidelines for management of diabetic gastroparesis noted that a gastric electrical stimulator may be considered for compassionate treatment in patients with refractory symptoms, particularly nausea and vomiting (Camilleri, et al). This patient has attempted available medications for gastroparesis, has experienced weight loss, and has required multiple hospital visits due to uncontrolled disease. For these reasons, the requested Enterra device to the stomach is supported as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 Lyrica for treatment of her medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior effectiveness of the requested medication.  This patient was diagnosed with chronic right knee pain.  Lyrica is an anticonvulsant which is approved for chronic pain associated with neuropathic pain, fibromyalgia and diabetic neuropathy.  There is lack of support in the medical literature for treatment of chronic knee pain with this medication.  Thus, Lyrica is not likely to be more efficacious than other treatment alternatives in this clinical setting.  Final Result: The reviewer determined that the requested medication is 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: 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested an implanted infusion pump for treatment of the enrollees medical condition.  Findings:  Two physician reviewers found that an implanted infusion pump was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient has progressive metastatic disease. Systemic opioids cause grogginess and severe constipation. The use of an implantable pump for this patient is standard care, medically appropriate, and consistent with current medical evidence. Moreover, a trial with an external pump is not required for the permanent placement of an intrathecal infusion pump. All told, the services at issue were likely to be more beneficial for treatment 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 treatment 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.
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 treatment of her medical condition.  Findings:  Two physician reviewers found that the LINX device has been approved for patients with diagnosed gastroesophageal reflux disease as defined by abnormal pH testing, and who continue to have chronic gastroesophageal reflux disease symptoms despite maximal medical therapy for the treatment of reflux.  This patient has documented gastroesophageal reflux disease based on endoscopic and radiographic data.  However, it is documented she has benefited to a significant degree from acid suppression treatment, and as such cannot be considered medically refractory to acid blocker drugs.  Further, implantation of LINX in this clinical setting must be approached with caution given her documented complaints of dysphagia and the manometric finding of ineffective esophageal motility. In sum, the requested LINX anti-reflux procedure is not likely to be of greater benefit than other treatment options. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a Botox injection for treatment of the enrollees chronic migraines. Findings:  Three physician reviewers found that recent studies show that Botox (botulinum toxin) injections are an effective, safe, and well-tolerated treatment for the prevention of headaches for patients with chronic migraine headaches. The U.S. Food and Drug Administration approved Botox in patients with adult chronic migraine who suffer headaches on 15 or more days per month for those headaches lasting more than four hours. To treat chronic migraine, Botox is given approximately every 12 weeks as multiple injections around the head and neck to try to dull future headache symptoms. But in this patients case, the submitted records have not indicated episodic migraine headaches that occur 14 days or more per month. Moreover, there is no documentation of headache frequency or symptoms in association with the headaches which support a diagnosis of chronic migraine. As such, the submitted documentation fails to demonstrate the superior efficacy of the service at issue over available standard treatment options for this patient.  Final Result:  Three reviewers determined that the service at issue was 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: One reviewer is board certified in neurology with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in neurology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested lumbar spinal fusion for treatment of her medical condition.  Findings:  The physician reviewer found that the records provided document an incomplete examination with absence of back, hip, vascular and sacroiliac examinations. Thus, all other potential causes of her pain have not been ruled out. The criteria for fusion surgery requires symptomatic spondylolisthesis with functional impairment or progressive neurologic deficit, significant or moderately severe spinal stenosis with instability with functional impairment, which have not been documented. Further, there is no evidence of fracture, tumor or infection. Moreover, the patient has not failed at least six months of conservative management including cognitive behavioral therapy, which is indicated due to her history of depression. All told, the requested lumbar spinal fusion is not medically necessary for treatment of this patients chronic back pain.  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 neurological 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 general anesthesia for treatment of his medical condition.   Findings:  The physician reviewer found that medical literature supports the use of conscious sedation and intravenous sedation for dental treatments in patients with mental disabilities performed by a non-anesthesiologist and non-certified registered nurse anesthetist. In this case there is no documentation of the degree of mental disability to support the need for general anesthesia. However, the patient is morbidly obese. Thus, he has an American Society of Anesthesiology preoperative physical status classification score that will require an anesthesiologist for consultation. Therefore, the requested general anesthesia is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in 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 an orchiectomy for treatment of her gender dysphoria.   Findings:  The physician reviewer found that based on the medical records provided for this review, the patient has well-documented gender dysphoria. She has undergone the recommended evaluation and consideration for gender transition.  Her transition is supported by multiple therapists and physicians.  She has been living socially as a female and has undergone hormonal therapy for an extensive period of time. According to the publication by Schechter, Prior to performing gender reassignment surgery, the surgeon must be satisfied that the diagnosis of gender dysphoria has been established. This patient meets this criterion. Further, Schechter indicates After the diagnosis of gender identity disorder is made, the therapeutic approach commonly includes three phases (triadic therapy): a real-life experience in the desired role, hormones of the desired gender, and surgery to change the genitalia and other sex characteristics. As noted above, the patient has been living as a female and has also received hormone therapy. Thus, the next appropriate step is bilateral orchiectomy as part of the surgical transition process. All told, the submitted documentation demonstrates the patient has been living socially as a female, has been undergoing hormonal therapy for the recommended amount of time and her decision and condition is supported by her therapists and physicians.  Therefore, the requested orchiectomy is medically necessary for treatment of the patients medical condition. With regard to whether the proposed procedure meets reconstructive surgery criteria, the presence of bilateral testicles would be considered abnormal for a female. Further, the patient is well-documented to have gender dysphoria which can be considered a congenital or developmental abnormality. The requested orchiectomy is part of the surgical male to female transition and thus would improve function as it would contribute to a lower testosterone level and would also create a more normal female appearance. The proposed procedure is likely to provide more than a minimal improvement in the appearance of the patient. As such, the requested orchiectomy is considered reconstructive in nature. Final Result: The reviewer determined that the requested service is medically necessary for treatment of the patients medical condition and reconstructive in nature. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in plastic 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.