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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition. Findings: Two physician reviewers found that guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Therefore, advanced lipoprotein testing was not likely to have been superior over other methods of evaluating this patient.  Final Result: Two of the three reviewers 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 cardiovascular disease 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 intradiscal electrothermal annuloplasty (IDET) for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Despite the large number of procedures performed, a critical appraisal of the evidence of efficacy of IDET demonstrates that the evidence for efficacy of IDET remains weak and has not passed the standard of scientific proof.  The current medical evidence does not support the requested services in this patients case.  All told, the requested IDET is not medically indicated for the treatment of this patient.  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 neurological surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her breast cancer screening. Findings: Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  Final Result: All 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a blood test for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient presents with significant coronary risk and an episode of chest discomfort.  In this circumstance, guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. Thus, the services at issue were not 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 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 cardiovascular disease 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 F5 gene analysis, and Leiden variant testing for evaluation of her medical condition.  Findings: The physician reviewer found that according to the American College of Obstetricians and Gynecologists (ACOG) Inherited thrombophilias are associated with an increased risk of venous thromboembolism and also have been linked to adverse outcomes in pregnancy. However, there is limited evidence to guide screening for and management of these conditions in pregnancy. The American College of Medical Genetics in its Consensus Statement on Factor V Leiden Mutation Testing indicates that testing may be considered in relatives of individuals known to have Factor V Leiden, personal history of venous thrombosis or women with venous thromboembolism during pregnancy. In this case, the patient does not have a personal history or family history of venous thromboembolism or thrombophilia. Therefore, F5 gene analysis, Leiden variant testing, was not medically necessary for evaluation of the patients medical condition.  Final Result: The reviewer determined that the services at issue were 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 obstetrics and gynecology 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 a consultation with a plastic surgeon for treatment of her gender dysphoria. Findings: The physician reviewer found that review of the submitted documentation reveals that the patient is prepared for the next step of a surgical evaluation.  The patient has had previous gender reassignment surgery, which demonstrates she is an appropriate candidate for gender transition services. Consultation for further surgical intervention is the next appropriate step in the treatment of the patients gender dysphoria. Therefore, the requested plastic surgery consultation is medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested service 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested general anesthesia for treatment of his dental condition. Findings: The physician reviewer found that studies have shown that adults with developmental disabilities can be safely managed under general anesthesia for dental treatment in an operating room/hospital setting with minimal morbidity and without extensive preoperative investigations. A study by Bader and colleagues looked at pediatric patients who received dental care under general anesthesia. The most common indication for general anesthesia is the patients inability to cooperate and undergo dental treatment under local anesthesia. Because dental restoration under general anesthesia does not require cooperation from the patient it is a very efficient treatment modality. It can usually be completed in one procedure. Similarly, general anesthesia for adults with developmental delay is generally considered to be a safe and effective practice. This patient presents with significant cognitive impairment and is unable to cooperate with and therefore unable to tolerate dental treatment in an office setting. The documented impression is of a chronic dental disorder requiring complete examination and treatment in an operating room. The patient has met accepted criteria for general anesthesia as outlined in the medical record. Use of in office conscious sedation is not feasible based on the medical needs of the patient. For these reasons, administration of general anesthesia is medically necessary and appropriate in this case.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients dental condition.  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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested home nursing services for treatment of her medical condition. Findings:  The physician reviewer found that upon review of the record, home health services to administer the medication are not medically necessary because the documentation submitted does not demonstrate that the patient is homebound. Although the subcutaneous infusion of immunoglobulin is medically necessary for the treatment of the patient's condition, the patients record demonstrates that she is able to receive infusion at an outpatient medical facility. According to the medical literature cited, common variable immunodeficiency (CVID) includes individuals with varying degrees of loss of antibody. For those with substantial impairments in antibody production and nonresponse to protein and carbohydrate vaccines, immune globulin (IG) replacement is necessary. The use of immunoglobulin replacement has been shown to reduce both hospital admissions and antibiotic use in patient's suffering with this condition.  In this case, the patient is not homebound and therefore the use of home health services in treatment of the patients medical condition is not medically necessary. 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 internal 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:  The parent of an enrollee has requested Nucala (mepolizumab) for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the patients allergist, has drawn a comparison between eosinophilic gastritis and Eosinophilic Esophagitis (EoE), speculating that the long-term complications of eosinophilic gastritis may include the type of fibrosis that can be seen in the esophagus of patients with EoE. In EoE, this fibrosis can lead to esophageal narrowing and structuring, with swallowing dysfunction.  However, there is not a clear association between eosinophilic gastritis and mechanical gastric dysfunction. Considering the published literature, mepolizumab is not medically indicated in the clinical setting of eosinophilic gastritis. There is a lack of evidence in the peer-reviewed literature supporting Nucala (mepolizumab) would be helpful in this clinical setting. 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 16 hours total of skilled nursing services per day for treatment of her medical condition.  Findings:  The physician reviewer found that the patient has end-stage amyotrophic lateral sclerosis.  The patient receives eight hours of skilled nursing services and the request is for an additional eight hours of service.  The documentation submitted does not support that the patient has had any new medical complications that would require an additional eight hours per day of skilled nursing services.  The Health Plan is currently providing eight hours of care daily by a skilled nurse which is adequate for oversite of plan of care and wound care.  The patient requires custodial care 24 hours a day, around the clock.  A skilled nurse is able to teach a layperson to care for a feeding tube and to suction via the tracheostomy.  Currently, the patient is not having an active infection or complication that would require an additional eight hours of skilled nursing service a day.  All told, the requested 16 hours total of skilled nursing services per day is not medically indicated for the treatment of this patient.  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 internal medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 3D breast tomosynthesis for evaluation of her breast cancer screening. 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. Therefore, in this clinical setting, the tomosynthesis was likely to be more beneficial than breast sonography as a screening tool alone.    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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested 32 hours per week of direct intensive applied behavioral analysis (ABA) therapy for treatment of the enrollees medical condition. Findings:  Two physician reviewers found that the request for 32 hours per week of direct intensive of ABA therapy of which 24 hours to be rendered in the school setting are medically necessary for treatment of the patients medical condition. The study by Orinstein and colleagues found that children with optimal outcome from autism spectrum disorders (ASD) had started therapy earlier and had more ABA services. ABA therapy is medically necessary for the treatment of autism spectrum disorders. In addition, ABA services should be performed in the appropriate setting for the particular patient. In this case, there has been a regression of the patients autism-based behaviors in the classroom setting that are interfering with his academics. Given the above, the requested ABA hours in the classroom setting are medically necessary for treatment of the patients medical condition.  Final Result: Two reviewers determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: One reviewer is board certified in child neurology and is actively practicing. One reviewer is board certified in pediatrics and child neurology and is actively practicing. One reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics and is actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the medical records document coronary risk and dyslipidemia.  In this circumstance, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations.  These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2, sub-classifications of low-density lipoprotein, high-density lipoprotein subclasses, lipoprotein (a), C-reactive protein, high sensitivity C-reactive protein, insulin, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  In sum, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three reviewers 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 cardiovascular disease and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested bilateral foot orthotics for treatment of his medical condition.  Findings:  The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  The patient has congenital abnormalities in his foot architecture bilaterally which appear consistent with pes cavus. He is reporting significant foot pain with a sense of bilateral foot dislocation, causing functional difficulty in activities of daily living. There is imaging evidence of a high intermetatarsal angle with medial sesamoid fracture. He has utilized orthotics since childhood and the previous orthotics were reported as not currently effective. Custom molded orthotics by the podiatrist to stabilize the current fracture and address the structural abnormalities is consistent with current evidence-based literature. Therefore, the requested bilateral foot orthotics are medically indicated for the treatment of this patient. 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 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.