Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zoll wearable cardioverter defibrillator vest for treatment of the enrollees dilated cardiomyopathy, myocarditis, and acute systolic congestive heart failure.  Findings: Two reviewers found that in this circumstance, there is potential for recovery of left ventricular function over time with medical therapy and there is no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until a period of time, approximately 90 days has elapsed, when continued left ventricular dysfunction of 35% or less is documented to persist in spite of appropriate treatment (Russo, et al). A prophylactic defibrillator (wearable or implantable) before this time has passed has not been demonstrated to improve health outcomes (Hohnloser, et al; Steinbeck, et al). In addition, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups (Chung, et al). All told, the requested Zoll wearable cardioverter defibrillator vest is not 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 device 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 90/400 for 12 weeks 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.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines note that non-cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks.  These 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.  The current guidelines cite data showing reduced survival with delayed treatment.  For these reasons, Harvoni 90/400 for 12 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Per colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.  Colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. Final Result: 2/3 of the 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested for a positron emission tomography (PET) scan for evaluation of the enrollees squamous cell carcinoma of the rectum. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  This patients initial PET scan was positive.  Subsequently, on the follow-up PET scan, there was a partial response with diminished uptake.  Complicating matters, however, is that radiation therapy can, in itself, result in fludeoxyglucose (FDG) uptake.  Thus, while it is a good sign that the activity on the follow-up PET scan had diminished, one does not know whether there are post radiation changes or whether there is residual tumor.  The patient then had another follow-up PET scan in the spring which again revealed residual activity.  Generally, the changes related to radiation therapy should be resolving after six months, and it was presumably this residual activity which led her provider to perform a repeat endoscopy and biopsy.  The biopsy results were negative.  However, at this point, it is still not clear whether there is residual tumor.  The fact that her biopsies were negative does not exclude the possibility that the residual tumor simply was not sampled.  At this point, the FDG activity should be diminishing.  If not, there is a more likely possibility that there is residual tumor.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested PET scan is medically indicated for the evaluation of this patient.Final Result: The reviewer determined that the requested services are medically necessary for evaluation 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 reimbursement for digital breast tomosynthesis.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.  In this patients case, her breast tissue was described as heterogeneously 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.  Final Result: Three 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 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 inpatient hospitalization level of care services for treatment of the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Per the medical records, clinical services could not have reasonably been delivered in a less restrictive setting while outpatient treatment would have resulted in inadequate care.  Due to the acute psychiatric syndrome with concern of suicidality and behavioral dysregulation, psychiatric hospitalization was initially indicated.  The patient promptly engaged the services afforded by the inpatient setting, including the initiation of a novel antidepressant.  The services and setting were safe, appropriate and consistent with good medical practice.  Nursing documented a normal mental status examination with mild depression.  The patient was not psychotic, suicidal, confused, boisterous or threatening.  The psychiatrist indicated that the patient was depressed, anxious, isolative, and felt hopeless and helpless.  The patient had no suicidal ideation or cognitive impairment, and was deemed to have good impulse control.  The patient had another reassuring nursing report.  According to the records, the patient was tolerating his new medication and understood that it would take time to determine its suitability in his case.  His thought processing was goal-directed, and he had no suicidality.  Further, he was attending to his activities of daily living, which he had been neglecting prior to admission.  During the course of the admission, although mildly depressed, the patients acute psychiatric syndrome resolved, and he did not voice any new complaints or express any suicidal ideation, homicidal ideation or aggressive behavior.  Thus, inpatient hospitalization levels of care services were medically necessary, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue was medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially 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: Upheld Decision of Health Plan

An male enrollee has requested authorization and coverage of Percocet 5/325 (four times per day). Findings:  The physician reviewer found that tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. In this patients case, as noted by the opioid risk assessment tool, this patient is at moderate risk with his personal history of alcohol abuse and depression. With his new provider, this patient appears to be currently more compliant with two consecutive appointments being completed. However, the medical literature supports a lower dosing regimen as prescribed by the treating provider.  As such, the requested Percocet 5/325 (four times per day) is not medically necessary for 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 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 Praluent 150 mg/mL for treatment of the enrollees hyperlipidemia.  Findings: The physician reviewer found that the patient in this case has CAD, has sustained a myocardial infarction, underwent a coronary artery bypass graft, and was treated with multiple percutaneous interventions and stenting procedures. In addition, he is noted to be a diabetic and has failed treatment with maximally tolerated doses of high potency statins including rosuvastatin and atorvastatin as well as simvastatin and pravastatin. Adjunctive therapy with Zetia, Welchol, and Niaspan has been documented with failure of treatment. The patients most recent LDL was 142 mg/dL, which is significantly above goal of less than 70 mg/dL. The National Lipid Association guidelines support reduction of LDL levels in patients such as the patient in this case. All told, the requested agent, Praluent is indicated for this patient based on the fact that he has failed multiple stations as indicated above, has significant CAD, and is currently not at goal in terms of LDL level. Since this patient has demonstrated intolerance to four statins at maximally tolerated doses due to muscle pain, and has not been brought to goal with Welchol, Zetia, or Niaspan, the requested Praluent 150 mg/mL is supported as medically necessary.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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for the evaluation of the enrollee, who was asymptomatic with respect to her breasts. Findings:  The 3 physician reviewers found that the patient is a female who was asymptomatic with respect to her breasts.  She underwent a routine screening mammogram consisting of a combination two dimensional and three dimensional digital breast tomosynthesis examination.  The current images were compared to prior mammograms, and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis used.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 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.  In this particular patient, the patients breast tissue has been described as being heterogeneously dense. While her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from digital breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, digital breast tomosynthesis used was likely to have been of greater benefit than other methods of evaluating this patient.  Final Result: The 3 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: Physician reviewer number one 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.Physician reviewer number two 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.Physician reviewer number three 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 reimbursement for a lymphoscintigraphy with single photon emission computed tomography/computed tomography (SPECT/CT) for evaluation of the enrollees melanoma. Findings: Three physician reviewers found that Lymphoscintigraphy in patients with melanoma is recognized as a valuable diagnostic procedure in pre-operative localization of the sentinel node. The addition of SPECT with CT imaging is of value over planar imaging with improved spatial and contrast resolution with a more detailed and accurate mapping of regional draining and sentinel nodes. Resection and biopsy of these nodes has been proven to have an impact on patient survival. For this reason, the addition of SPECT/CT was more advantageous to the patient than had the exam been done with planar imaging alone. Thus, the lymphoscintigraphy with SPECT/CT 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested back surgery for treatment of the enrollees back pain.  Findings: The physician reviewer found There is a lack of large volume, long-term peer-reviewed outcome studies to support the requested back surgery in this clinical setting. There is some medical peer-reviewed evidence to support the use of percutaneous balloon kyphoplasty for acute vertebral body fractures, less than three months from onset of pain to procedure. In this case, the patient had a traumatic T12 compression fracture that was 10 months old. She presented with moderate to severe persistent back pain. Moreover, other than the prescribed medications which the patient did not wish to take, there was a lack of evidence indicating that conservative treatment was performed. All told, the requested back surgery is not medically necessary for treatment of this patient.Final Result: The reviewer determined 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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for oxycodone-acetaminophen (Percocet) 10-325.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The records document a long history of chronic back pain.  This patient self-escalated his opiate medication and is in violation of his agreement.  The current medical evidence does not support the requested medication in this setting.  Clinical practice guidelines support tapering opiates when the agreement has been violated. 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.