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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollee, who was asymptomatic.Findings:  The physician reviewer 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, the records noted heterogeneously dense breast tissue.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the high intensity focused ultrasound (HIFU) for treatment of the enrollees prostate cancer. Findings:  Two physician reviewers found that technology regarding treatment of prostate cancer with HIFU has been evolving. HIFU has been demonstrated as a safe and effective method for the treatment of localized prostate cancer. The U.S. Food and Drug Administration (FDA) has confirmed the findings and approved the procedure for ablation of prostate tissue. There is no comparative study to evaluate the efficacy of HIFU compared to standard therapy such as surgery or radiation. However, there may be benefits as this procedure is less invasive with potentially lower complication rates. Currently, HIFU is an approved procedure for ablation of prostate tissue including prostate cancer. Final Result: Two reviewers determined that the procedure at issue was 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: All three physician reviewers number are board certified in urology 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 risk for breast cancer. Findings:  Two physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. 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 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 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. 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 Mohs micrographic surgery for treatment of the enrollees squamous cell carcinoma of the left forearm. Findings:  The physician reviewer found that squamous cell carcinoma (SCC) accounts for 16% of all skin malignancies and is the second most common skin cancer after basal cell carcinoma. SCC has a 95% cure rate when detected and treated early. However, a small subset may be aggressive with local recurrence, metastasis, and death. Numerous treatment options exist for SCC of the dorsal hand, and the decision depends on multiple variables. One study reported that cryosurgery with liquid nitrogen can be performed quickly in an outpatient setting with minimal specialized equipment. Another study found that for standard surgical excision, lower-risk SCCs require 4-mm margins to obtain 95% clearance. Indications for Mohs micrographic surgery include a large size measuring greater than 2 cm in diameter, ill-defined clinical borders, high-risk anatomic location, and aggressive histologic behavior, as well as perineural invasion, recurrent/incompletely excised tumors, prior exposure to ionizing radiation, chronic scar, immunocompromised state, and underlying genetic syndrome. Given these guidelines, this patient does not meet the medical necessity criteria for Mohs micrographic surgery. Final Result: The reviewer determined that the procedure 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 dermatology 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 enrollee, who presented for a breast examination. Findings:  Three physician reviewers found that the enrollee has a history of breast cancer. There was a lumpectomy performed on the left side. This study noted the breast tissue was average in density. There was stable postsurgical changes in the upper mid left breast. The impression was benign. The Health Plan has denied reimbursement for the digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to a study, 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.  Another study noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis performed was likely to have been more effective than other methods of evaluating this patient. 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: All three 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: The parent of an enrollee has requested authorization and coverage for a referral for a dermatologist and possible biopsy for treatment of the enrollees skin mole. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services. This patient has an irregular, changing, symptomatic pigmented lesion on the back.  The medical records indicate that the lesion is producing the symptom of itching.  These features are concerning for a dysplastic nevus or melanoma.  It is reasonable, prudent and medically necessary for the patient to have a dermatologic evaluation.  The current medical evidence supports the requested services in this clinical setting.  All told, the requested referral for a dermatologist and possible biopsy are medically indicated for the treatment of this patient. Final Result: The reviewer 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: The physician reviewer is board certified in dermatology 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 PancraGen testing for evaluation of the enrollees pancreatic cysts. Findings:  Two physician reviewers found that PancraGen is used to characterize pancreatic cysts and lesions, using carcinoembryonic antigen, amylase, and molecular analysis (or DNA sequencing) to characterize pancreatic cysts. As noted by one study, the American Gastroenterological Association technical review for diagnosis and management of neoplastic pancreatic cysts does not include a recommendation for use of PancraGen.  Another study noted that in patients undergoing surgical resection, molecular analysis of fluid had sensitivity of 50% and a specificity of 80% in identifying mucinous pancreatic cysts (accuracy of 56.3%), resulting in conclusion that further studies are needed to assess DNAs performance in malignant cysts.  Thus, PancraGen testing performed was not likely to have been more efficacious than other modalities for evaluating this patient. Final Result: The 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 authorization and coverage for a procedure to repair cartilage to the ankle, juvenile cartilage transplant (DeNovo) for treatment of the enrollees osteochondral lesion. Findings:  Two physician reviewers found that the request for a procedure to repair cartilage to the ankle, juvenile cartilage transplant (DeNovo) has been established as likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Particulated juvenile articular cartilage allograft transplantation for osteochondral lesions of the talus (DeNovo) is well-known to be an effective method for management of focal chondral defects. This method relies on the ability of juvenile chondrocytes to migrate from cartilage explants after being secured in a cartilage defect. Studies have demonstrated that it is a rapid, safe, and effective treatment for cartilage defects. According to the study by Farr and colleagues involving the articular cartilage of the knee, the clinical outcomes showed a significant improvement over the baseline with histologically favorable repair tissue two years postoperatively. In light of the foregoing, the request for particulated juvenile articular cartilage (DeNovo) is medically appropriate and likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: The reviewers determined that the requested procedure 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: All three physician reviewers are board certified in orthopedic surgery 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: The parent of an enrollee has requested authorization and coverage for continued group speech therapy for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that review of the submitted documentation demonstrates the medical necessity of continued group speech therapy. Based on the documentation submitted for review, the patient has difficulties with social skills in the home and school setting. The testing performed did not evaluate his skills in a social setting. In this clinical setting, group speech therapy is medically necessary to address his pragmatic speech problems that stem from the patients autism. All told, continued group speech therapy has been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer 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: The physician reviewer is board certified in pediatrics with sub-specialty certification in developmental and behavioral pediatrics 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 reimbursement for continued skilled nursing facility level of care provided for treatment of the enrollees medical condition status post pulmonary embolism. Based on the clinical documentation submitted for review, the medical necessity for skilled nursing facility level of care provided has not been established. In this case, the patients skilled nursing facility services were terminated. To safely discharge home, she needed a plan in place. The patient received custodial care which was appropriate pending discharge plan implementation to arrange a safe transition from the rehabilitation setting. Accordingly, continued skilled nursing facility services was not medically for treatment of the patients medical condition. Final Result: The reviewers 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: Physician reviewer number one 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for abdominal lipectomy.Findings:  The physician reviewer found that the patient has well-documented scenario of a symptomatic, abdominal pannus that has failed reasonable conservative management.  Her symptoms include back and abdominal pain that affect her activities of daily living.  Work-up of her abdominal pain has included a CT scan which did not reveal an etiologic source from intra-abdominal findings.  She has evidence of chronic rashes and fungal infections directly related to her overlapping abdominal skin and pannus.  She has attempted to treat this condition with drying agents and antifungal medications. This is well documented and supported by multiple providers.  The likely cause of her functional deficits is directly related to the size and overhang of the abdominal pannus. Therefore, an abdominal lipectomy would directly address the size of the abdominal pannus and would likely correct the skin to skin overlap.  Moreover, the medical literature supports this procedure in this clinical setting. In summary, this patient has failed reasonable conservative management in the treatment of her medical condition. As such, further conservative management would not likely provide any substantial benefit. The area around the umbilicus has been a well-documented source of chronic yeast infections. Final Result: The reviewer determined that the requested procedure 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: A 56-year-old male enrollee has requested reimbursement for long-term acute care inpatient stay for treatment of  Guillain-Barre syndrome and West Nile virus. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.   Guillain-Barre syndrome generally has a favorable natural course and relatively good prognosis.  There are treatment options such as intravenous immunoglobulin and plasma exchange that have demonstrated to be effective treatments for this condition. However, despite the generally good prognosis and available therapeutic options, some patients continue to have significant functional impairments at six months or longer following the onset of symptoms.  To date, highly intensive rehabilitation services have not been proven to effectuate better long-term functional outcomes.  In this case, the patient has had multiple premorbid conditions and was reported to be disabled at baseline.  He underwent prolonged inpatient treatment and recovered his respiratory and swallowing function.  He has been undergoing rehabilitation, but has remained essentially dependent for care.  However, the records do not demonstrate that the patient has required long-term acute care (LTAC) level care.  LTAC level care is considered medically necessary when care is needed that is more medically complex than can be handled at lower levels of care such as inpatient rehabilitation, skilled nursing facility or outpatient care.  Examples of treatments that are considered consistent with this level of care include the following: chest tubes, extensive wound care, stable cardiac drips, multiple intravenous antibiotics, hemodialysis/peritoneal dialysis, prolonged intravenous therapy, total parenteral nutrition, tracheostomy care/extensive pulmonary services, ventilator weaning, and frequent imaging/laboratory testing.  Usually more than one of these treatments is being provided at the LTAC level of care.  There should also be documentation of prior treatment failure at lower levels of care and/or reasonable expectation of treatment failure at lower levels of care.  There is no documentation supporting that a LTAC level of care is necessary for this patient.  He has been weaned from mechanical ventilation and decanulated.  He is not on any intravenous therapy, total parenteral nutrition or other complex treatment that could not be provided at a lower level of care. Final Result: The reviewers 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

Nature of Statutory Criteria/Case Summary: The parent of a six-year-old female enrollee has requested authorization and coverage for Uptravi (selexipag) for treatment of the enrollees idiopathic pulmonary arterial hypertension. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication. Uptravi is an oral selective IP prostacyclin receptor agonist that functions to relax muscle in the pulmonary vascular bed.  Initially, this medication had orphan drug status.  However, in December 2015, the U.S. Food and Drug Administration (FDA) approved its use in adults with pulmonary arterial hypertension.  The package insert specifically notes not to use this medication in children under the age of 18 years because of the lack of experience in such patients.  There is a need for studies of this medication in children, and this medication is not currently approved for use in children. This patients pulmonary hypertension is well-controlled on her current medication combination.  Final Result: The reviewers 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 critical care 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.