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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Viekira Pak plus ribavirin for treatment of his 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 12 weeks.  The guidelines also cite data showing decreased survival with delay in therapy.  For these reasons, the requested treatment with Viekira Pak and ribavirin is 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: Medical Necessity
Decision: Upheld Decision of Health Plan

 Nature of Statutory Criteria/Case Summary:   An enrollee has requested monitored anesthesia care during a colonoscopy procedure for evaluation of his medical condition.  Findings:  The physician reviewer found that for this patient, there is no documentation of clinical findings that would support the need for monitored anesthesia. The patient has a low (ASA) preoperative physical status classification score, which indicates a healthy individual.  Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist are well supported in both clinical practice and in the research. Therefore, given a low preoperative physical status classification score,  monitored anesthesia care was not medically necessary during the patients colonoscopy procedure. The Health Plans denial should be upheld.  Final Result: The reviewer determined that the anesthesia services at issue were not medically necessary during the patients colonoscopy procedure. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in anesthesiology 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 pulsed radiofrequency ablation for treatment of his medical condition. Findings:  Three physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  There is a lack of clinical evidence in the form of well-designed, randomized clinical trials that demonstrate the benefit of pulsed radiofrequency ablation for chronic cluster headaches.  There is a need for high-quality randomized controlled trials supporting the long-term safety and efficacy of this treatment.  In the absence of adequate clinical data, the superior effectiveness of pulsed radiofrequency ablation has not been established. 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 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: 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:  Two physician reviewers found that digital breast tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) subsequently urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. Accordingly, 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: 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: Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  For this reason, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  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 physician 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. In addition, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis (Skaane, et al). Given the support above, 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 physician 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 breast tomosynthesis for evaluation of her medical condition. Findings: Three physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in patients with extremely dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of breast tomosynthesis to the usual two-dimensional views was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging 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 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two 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, breast tomosynthesis was likely to be more beneficial for evaluation of this 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Botox injections for treatment of her medical condition.  Findings:  Three physician reviewers found that Vulvodynia is a complex problem that is difficult to treat as the disease process is multifactorial without one specific etiology, and clinically can present in different ways and can change over time. The American College of Obstetricians and Gynecologists (ACOG) has addressed this complex condition and does not include Botox injections as a first- or second-line therapy. Botox does appear to be safe but it is currently not U.S. Food and Drug Administration (FDA) approved for this indication and not part of the ACOG algorithm of management. For these reasons, the requested Botox injections are 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 services at issue were not and 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 obstetrics and gynecology 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 gene testing (Uveal melanoma) for evaluation of his medical condition.  Findings:  Three physician reviewers found that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is sufficient support in the peer-reviewed literature demonstrating that this testing is more beneficial than standard therapy. Genetic testing of uveal melanoma tissue has proven useful in determining potential for metastasis, and guiding treatment for uveal melanoma. For the reasons stated above, the requested gene testing (Uveal melanoma) 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 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 ophthalmology and are 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 a positron emission tomography (PET) scan for evaluation of her medical condition. Findings:  The physician reviewer found that according to the documentation submitted for review, the patient is in remission from her monoblastic sarcoma-acute myeloid leukemia.  She has stable graft versus host disease and no signs or symptoms to warrant a PET scan. A PET scan is not indicated for surveillance and she has no signs or symptoms to suspect any malignancy or recurrence. All told, the requested PET scan is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested services are 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 medical oncology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that based on the documentation submitted for review, residential treatment center services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review do not demonstrate that the patient had severe emotional problems or symptoms which required 24-hour supervision. In addition, she did not have evidence of suicidality or homicidality, self-harming behaviors, physical aggression, impairment in activities of daily living, or disruptive behavior. The patient did not exhibit severe anxiety, and she was able to manage her emotions well. The patient was able to have a home visit during which no behavioral problems were identified. There was no evidence that the patient would have resulted in worsening of her condition due to the less restrictive outpatient level of care. Multiple notes throughout the course of the admission noted that the patient was having a good day.  She was consistently compliant with medications with no side effects of the medications. She appeared to have a supportive family and was cooperative with care. Throughout the patients admission, the few medication management changes that were made were minor adjustments and could have been performed in an outpatient setting.  Given the above, the services at issue were not medically necessary for treatment of the patients medical condition.  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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested peripheral bone density testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Bone density testing of the forearm may have been indicated if the patient had primary hyperparathyroidism or if there was a reason why the hip or spine images could not be read or interpreted.  In this patients case, there is no mention of hyperparathyroidism or any anatomic or surgical changes that would make the spine and hip difficult to read or interpret.  In sum, peripheral bone density testing was not likely to have been superior over other methods of evaluating this patient.   Final Result: The reviewer determined that the services at issue were not likely to be more beneficial for evaluation 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 endocrinology, diabetes and metabolism 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 acupuncture services for treatment of her knee pain.  Findings:  The physician reviewer found that the submitted medical records do not demonstrate the medical necessity of the requested service.  The patients diagnosis of osteoarthritis in her bilateral knees is unsupported by physical exam, orthopedic exam or x-ray findings. Moreover, the documentation does not indicate a limitation on her daily living activities nor are there any disabilities described. The records do not include a pain scale or an assessment showing improvement as a result of a trial of treatment. As such, the requested acupuncture is not medically necessary for treatment of the patients knee pain.  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 oriental 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 Orencia for treatment of her medical condition. Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The provider feels that given the patients systemic lupus erythematosus features, anti-tumor necrosis factor agents would be contraindicated.  Orencia is requested as it may be used without methotrexate.  In this case, the provider would prefer to use it without methotrexate given an inability by the patient to tolerate methotrexate.  Orencia has been approved for the treatment of patients with moderately to severely active rheumatoid arthritis who have had an inadequate response to one or more disease modifying anti-rheumatic drugs or tumor necrosis factor inhibitors.  This medication appears to be most effective in certain subsets of rheumatoid arthritis patients.  In this case, the patient is seronegative for rheumatoid factor.  The records fail to demonstrate any poor prognostic factors or radiographic evidence of joint erosions.  There is a lack of support for the requested medication in this clinical setting.  All told, Orencia 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 internal medicine 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.