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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for home health therapy services for treatment of her feeding difficulties with tracheostomy.  Findings:  The physician reviewer found that per the U.S. Department of Health and Human Services/National Institutes of Health (NIH), a child with Down syndrome likely will receive care from a team of health professionals, including, but not limited to, physicians, special educators, speech therapists, occupational therapists, physical therapists, and social workers. The guidelines note that physical therapy includes activities and exercises that help build motor skills, increase muscle strength, and improve posture and balance. Further, occupational therapy helps find ways to adjust everyday tasks and conditions to match a persons needs and abilities. This patients multiple medical issues include emesis due to stress, which would interfere with therapy and prolong the timing of therapy outside of the home. While the patient does not meet the Centers for Medicare and Medicaid Services (CMS) definition of homebound, when the patient is not at home and does not receive the services at home, she has episodes of emesis due to stress. Thus, the patient is in need of occupational therapy and physical therapy within the home and requires the assistance of another person and an assistive device in order to leave her residence. In order for the patient to leave her home to attend therapy, the parents would have a considerable and taxing effort to leave the home. The parents may need to bring tracheostomy supplies and feeding supplies dependent upon the length of therapy and timing of therapy outside of the home. The patient has received therapy in her home for five years. She is legally deaf, blind and non-verbal. The patient has additional complex issues including Downs syndrome and a tracheostomy. Final Result: The reviewer determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in pediatric rehabilitation 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: A female enrollee has requested reimbursement for chiropractic visits for treatment of the enrollees cervical root disorder.  Findings:  The physician reviewer found that There is a lack of medical evidence to support further clinical improvement from continuous ongoing chiropractic care in this clinical setting. The submitted records indicate that this patient has had extensive chiropractic treatments with no significant improvement or change to her medical condition. Each visit note appears to be very similar and no significant changes or improvements to the patients medical condition have been noted by her provider. Moreover, there is little information available from clinical trials to support manual adjustments as an effective therapy for mechanical neck pain. In general, conservative interventions have not been studied in enough detail to assess efficacy or effectiveness adequately. In this patients case, the submitted records do not support a lasting benefit or clinical improvement in her symptoms. For these reasons, the services at issue were not medically necessary for treatment of this 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 chiropractic care 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 reimbursement for prostatic urethral lift (PUL) procedure for treatment of the enrollees benign prostatic hyperplasia (BPH) with nocturia. Findings:  Two physician reviewers found that the Urolift procedure has been approved by the U.S. Food and Drug Administration (FDA) as an effective treatment of appropriately selected patients with benign prostatic hyperplasia. The Urolift procedure has been shown to be successful and safe in short-term outcomes. However, this patient has had a modified TURP. Therefore, the indications for Urolift procedure are not known. Further, this patient has had persistent symptoms of irritation along with obstructive symptoms and increased residual urine. Thus, an urodynamic study would have been appropriate to confirm bladder outlet obstruction including pressure flow studies, prior to repeat transurethral surgery. Since the records do not document that an urodynamic study was performed prior to the Urolift procedure, the PUL procedure performed was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the procedure 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: Physician reviewers 1, 2, and 3 are board certified in urology 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis performed. Findings:  The physician reviewer found that in this case, the digital breast tomosynthesis performed on the dated of dispute was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. previous month's study was a baseline mammogram, and it was noted that she had heterogeneously dense breasts. In addition, there were questionable areas of distortion in each breast and she was recalled for additional imaging. It is specifically those patients who have dense breasts and areas of architectural distortion that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. For the reasons provided, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Physician reviewers 1, 2 & 3 are board certified in diagnostic radiology and are actively practicing. The reviewer s 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 authorization and coverage for Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation. Findings: The physician reviewer found that the patient ihas intractable interstitial cystitis. the patient is noted to have significant painful voiding syndrome. The patient has had multiple therapies in the past including numerous oral agents. The patient has had sacral nerve stimulator inserted resulting in improvement in her voiding symptoms. However, she continues to have significant painful voiding syndrome with suprapubic pain. This has been quite disabling. She has tried subsequently pelvic floor therapy and diet. The patient reported significant improvement with intravesical therapy. The documentation indicates that this patient has had disabling symptoms related to interstitial cystitis. She has been placed on multimodal therapy with medications but has had minimal improvement in her symptoms. She has had some success with intravesical instillation therapy. This included combination therapy with Solu-Cortef Marcaine/Lidocaine, sodium bicarbonate and heparin. The patient is requesting authorization and coverage for Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation. The Health Plan denied the request noting that the requested mixture is investigational for the treatment of this patient. The American Urologic Association (AUA) approves intravesical therapy for refractory interstitial cystitis. Furthermore, they indicate that the treatment should be based solely on the relationship between the provider and the patient. This is very important, as this is a difficult disease to manage and is poorly understood. Therefore, treatment options are limited. This patient has demonstrated severe and debilitating symptoms as a result of her condition. As such, she meets the criteria outlined by AUA. In sum, Solu-Cortef, Marcaine, heparin, Lidocaine and sodium bicarbonate mixture for bladder instillation is likely to be superior to other treatment modalities for the treatment of this patient.Final Result: The reviewers determined that the requested mixture is 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: Physician reviewers 1, 2 & 3 are board certified in urology and are actively practicing. The reviewers are expert sin 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 the digital breast tomosynthesis for evaluation of her breast cancer examination. Findings:  The physician reviewer found that tomosynthesis is rapidly becoming a standard tool in evaluating dense breasts or suspicious calcifications. In this case, the patient 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. 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: Physician reviewers 1, 2, and 3 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 the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  Three physician reviewers found that 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 advantage it brings radiologists interpreting mammograms especially in women with dense tissue such as the patient under review. This tomographic method often allows the reader to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in diagnostic accuracy compared to two-dimensional (2D) imaging alone. Thus, the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had the exam been done with 2D imaging only.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: an enrollee has requested authorization and coverage for intravenous (IV) Stelara. Findings:  The physician reviewer found that Stelara is the biologic therapy most recently approved by the U.S. Food and Drug Administration (FDA) for treatment of Crohns disease. Two randomized, placebo controlled trials formed the basis for the FDA approval. However, there has not yet been a head-to-head trial of Stelara compared to Humira. There is also evidence demonstrating improved health outcomes with use of Humira in long-term studies, which are not available for Stelara. This patients treatment for Crohns disease has included use of steroids and Lialda. The records do not document either a lack of response or unacceptable side effects from steroids. The patient also has not been treated with anti-TNF agents such as Humira. Currently, there is a paucity of data supporting the clinical utility of Stelara for treatment of Crohns disease when first-line treatments have not been exhausted. Further, although the patient expressed concern regarding hepatosplenic T-cell lymphoma (HSTCL), there has only been one case reported in a patient who used Humira without concomitant immunosuppression. All told, the requested IV Stelara is not medically necessary for treatment of this patients medical condition. 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 pediatrics with sub-specialty certification in pediatric 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 authorization and coverage for breast reduction surgery for treatment of the enrollees hypertrophy of breast. Findings:  The physician reviewer found that in this case, the patient has documented evidence of symptomatic macromastia. Her symptomatology, examination detail and review of the photographs are supportive of this diagnosis. She has multiple functional deficits supported by typical signs and symptoms associated with macromastia. She has neck, back, shoulder and breast pain. She has evidence of significant macromastia on review of the photographs. Her chronic pain has failed conservative management with multiple medications and physical therapy. The degree of resection planned of 800 grams is also supportive of significant macromastia. The patients macromastia is causing functional problems are directly related to her macromastia. Breast reduction is a well-known procedure that directly addresses functional compromise. Final Result: The reviewer determined that the requested surgery 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 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha 140 mg/mL SureClick, every two weeks for treatment of the enrollees mixed hyperlipidemia, hypertensive disease and status post myocardial infraction.Findings:  The physician reviewer found that the patient presents with known coronary disease, hyperlipidemia and intolerance to all statin medications. In this circumstance the use of a PCSK-9 inhibitor is reasonable and appropriate. PCSK-9 inhibitors have been studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol such as this patient. Randomized trials have demonstrated outcome improvement with this medication class.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 cardiovascular disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuedexta 20/10 mg capsules twice per day, #60 per 30 days for treatment of the enrollees severe head and neck injury occurring after a fall. Findings: The physician reviewer found that in the medical literature, Nuedexta has been demonstrated to be effective for treatment of pseudobulbar affect (PBA). A study noted that PBA is a dysfunction of emotional expression characterized by involuntary outbursts of crying or laughing disproportionate or unrelated to mood, occurring in patients with various underlying neurologic disorders. Another study demonstrated that Nuedexta is supported for treatment of PBA. However, this patients medical records do not document symptoms consistent with a diagnosis of PBA. Accordingly, the requested Nuedexta 20/10 mg capsules twice per day, #60 per 30 days is not medically necessary for treatment of this patients medical condition. 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 neurology 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 authorization and coverage for plastic/reconstructive surgery for treatment of the enrollees atrophic pitted scar of the face. Findings:  The physician reviewer found that the patient presents with an indented atrophic scar of the left chin that is 3 mm wide and less than 1 mm in depth after previous cryotherapy in March 2016. Based on the most recent evaluations, it does not appear that the scar is immature. Documentation from 10/25/16 noted that the scar is atrophic/indented and documentation from 11/10/16 reported that the scar is depressed. There was no mention of color of the facial scar or that it was hypertrophic. Although the recommendation was to wait at least one year following cryotherapy, there is no evidence of ongoing scar inflammation or immaturity and the scar is unlikely to significantly change with further elapse of time. In addition, a scar indentation after greater than eight months is unlikely to change significantly. At this point based on the above reasoning, the scar is likely fully mature and not likely to improve or change significantly. Final Result: The reviewer determined that the requested surgery 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 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.