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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for continued skilled nursing facility level of care from 11/05/16 forward.  Findings:  The physician reviewer found that this patient has sustained a cerebral insult due to neoplastic disease.  He had deficits in cognition and overall functioning, which are not unexpected in this setting.  However, he has responded to treatment that has included intravenous steroids, surgical tumor resection, relative rest, and inpatient rehabilitation efforts.  As of 11/05/16, he was at the supervision level for self-care and basic household level mobility.  He had not yet started brain radiation.  Further care, including rehabilitation interventions, could have been provided in the community/outpatient setting, with caregiver supervision in the residential setting for safety.  He did not have documented treatment needs, such as multiple or frequent intravenous antibiotics, new complex wounds, or other skilled nursing needs, that required ongoing inpatient hospital level care. Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation 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

The parent of a minor enrollee has requested authorization and coverage for removal of teeth numbers 1 and 16. Findings:  The physician reviewer found that the radiograph provided does not demonstrate any pathology associated with teeth numbers 1 or 16, and appears to show adequate space present to allow normal passive eruption of these teeth.  The radiograph does not demonstrate etiological factors for pain caused by the presence of teeth numbers 1 and 16 other than the potential for the discomfort normally associated with tooth eruption.  The morbidity risk associated with prophylactic extraction of third molars when not dentally necessary has led to a need to assess risk versus benefit of extractions where no pathology is demonstrated.  The submitted surgical notes indicate that extraction of tooth number 1 was performed due to perforation of the tissue and inflammation, and extraction of tooth number 16 was performed due to complete bony impaction.  However, the radiograph provided does not demonstrate pathology associated with either of these teeth which would necessitate their extraction.  All told, removal of teeth numbers 1 and 16 was not dentally necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not dentally necessary for treatment of the patients dental condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in dentistry 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

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: the 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

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in an increase in accuracy, increase in detection of small cancers and decrease in callbacks compared to when imaging is done using the two-dimensional technique only. Final Result: The 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. The 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 authorization and coverage for Harvoni 90/400 mg for 12 weeks for treatment of the enrollees chronic hepatitis C virus genotype 1a.Findings:  The physician reviewer found that according to the most recent 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 AASLD/IDSA guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that non-cirrhotic treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks, and the medications are U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage. The guidelines recommend either Harvoni or Zepatier as acceptable therapy. There is a need for NS5A resistance testing prior to Zepatier in genotype 1a. The AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. 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 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

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, 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: 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: the 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 authorization and coverage for high back shower/chair/commode with wheels for treatment of the enrollees quadriplegia. Findings:  The physician reviewer found that it has been long established in the rehabilitation of spinal cord injury that many factors must be taken into account to optimize a patients bowel regimen. Positioning, while side lying or sitting, may be utilized for bowel evacuation after spinal cord injury. Sitting is preferred if this position is well tolerated. A case study showed different seating and backrest combinations including the sling seat and sling backrest, similar to what the patient uses with a camping chair. Sling supports are an inferior means of reducing pressure and optimizing spine and pelvic positioning. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for a custom oral appliance (E0486NU) for treatment of the enrollee, who has been diagnosed with obstructive sleep apnea.Findings:  The physician reviewer found that there is a lack of support for the requested equipment in this clinical setting.  The patients Epworth Sleepiness Scale score was 3, which was normal, and there was no hypersomnia.  Per the clinical documentation, he was not obese.  He filled out a form from a dentist noting he was not tolerant of CPAP.  However, the records do not show that he had a CPAP titration study documenting the optimal setting for CPAP treatment. Additionally, there is no documentation that he was treated with CPAP for a three-month period by a medical sleep medicine specialist.  The home sleep studies that he had were not the standard of care facility-based sleep study with an attendant who is certified.  Final Result: The reviewer determined that the requested equipment 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 pulmonary 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for multiple seat function kit (E2311) for treatment of the enrollees Duchenne muscular dystrophy. Findings:  The physician reviewer found that the benefits of power-mobility devices are reported to include improved quality of life, an increased sense of freedom and improved self-esteem. In this case, the patient has personal mobility and self-care deficits which the requested equipment will lessen. In addition, the requested device increases flexibility of positioning to reduce the risk of skin breakdown and makes him more independent. The requested multiple seat function kit will likely improve his ability to transfer, reposition to relieve pressure, and participate in activities of daily living. As such, the requested multiple seat function kit (E2311) has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation with sub-specialty certification in neuromuscular 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 authorization and coverage for Letairis (ambrisentan) and Adcirca (tadalafil) for treatment of the enrollees pulmonary hypertension.Findings:  The physician reviewer found that the management of PAH was initially limited to continuous intravenous infusions of prostacyclin, a difficult drug to administer and tolerate. In the past several decades there has been an abundance of compounds available and methods of administration. The most recent data on the management of PAH comes from the AMBITION study. The authors found that among treatment naive patients, a two drug regimen demonstrated a significantly lower risk of treatment failure than starting drugs individually. Specifically, the study concluded that among participants with pulmonary arterial hypertension who had not received previous treatment, the risk of the composite outcome of clinical failure was significantly lower among those who received initial combination therapy with ambrisentan and tadalafil than among those who received monotherapy with either ambrisentan or tadalafil. In this case, the patient has been recently diagnosed with PAH, and she is treatment naive. 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 physician reviewer is board certified in internal medicine with sub-specialty certification in critical care medicine and pulmonary 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

An enrollee has requested authorization and coverage for OxyContin 10 mg, twice daily. Findings:  The physician reviewer found that this patient had pain which was not adequately controlled with doses of immediate release oxycodone and non-steroidal analgesics such as ibuprofen. He required increased analgesic doses and sustained release and breakthrough short acting opioid analgesic.  It is understandable that the provider would choose OxyContin since the patient was already on short acting oxycodone. However, there is no reason to expect sustained release morphine, at equianalgesic dose, would not be as effective. Therefore, in this patients case, the requested OxyContin 10 mg, twice daily is not medically indicated 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 internal medicine with sub-specialty certification 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for gene expression profiling Decision Dx UM assay (CPT 84999) for evaluation of the enrollees uveal melanoma. Findings:  The physician reviewers found that the current medical evidence favors the use of this test in the post-operative surveillance of patients with ocular melanoma. All told, the gene expression profiling Decision Dx UM assay (CPT 84999) was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two of three reviewers determined that the testing 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in medical oncology and 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

An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that the patient is asymptomatic with respect to her breasts. The patient has a history of a prior augmentation mammoplasty. The patient underwent a routine screening mammogram consisting of a combination two-dimensional (2D) and three-dimensional (3D) tomosynthesis examination. Implant displacement views were also obtained. In addition, the patient had an automated whole breast sonogram exam.  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. No abnormalities were noted with regards to the implants. The whole breast automated sonogram also did not detect any abnormalities. Her breasts were described as extremely dense. In this particular patient, the presence of implants is not, in itself, an indication for tomosynthesis. For patients with implants, it is important to obtain implant displacement views to better evaluate the native breast tissue, which was done in this case. The patient also has breasts that have been described as extremely dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: 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 reimbursement for skilled nursing facility services received from 7/26/16 through 8/1/16.Findings:  The physician reviewer found that the patient sustained bilateral ankle fractures and had been immobilized with non-weight bearing restrictions.  She had undergone inpatient rehabilitation and had progressed as of 7/26/16 to a functional level where further care could have been provided in a lower level of care.  At that time, she required supervision for her self-care and household level mobility at a wheelchair level. There were no ongoing goals or needs requiring inpatient level rehabilitation, as further rehabilitation goals were precluded by her bilateral lower limb non-weight bearing status. The medical literature notes, there is little evidence for rehabilitation interventions during the immobilization period following ankle fractures, outside of optimizing general function, like from a wheelchair level.  In general, the marginal benefits of supervised exercise in the setting of ankle fractures are questionable.  There were no complex wounds or other skilled needs requiring ongoing inpatient level of care.  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 physical medicine and rehabilitation 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.