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

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage of a cooling or combined cooling/heating device (polar care unit) for treatment of the enrollees anterior cruciate ligament (ACL) reconstruction. Findings: Two physician reviewers found that there is a lack of scientific evidence showing the use of cooling devices improve outcomes following ACL surgery. Further, these devices are not included in any evidence-based treatment guidelines. Some studies have suggested short-term pain relief, but no effect on long-term outcomes. Cooling is frequently recommended after surgery, but can be accomplished with readily available materials such as bags of ice. Adie and colleagues review of commercial cold therapy following total knee replacement surgery concluded that potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or low for all main outcomes. The authors further noted that well-designed randomized trials are required to improve the quality of the evidence. Based on the available scientific data, the cooling or combined cooling/heating device (polar care unit) was not more likely to be more beneficial than standard available alternatives for this patient following ACL surgery.  Final Result: Two reviewers determined that the device 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: All three physician reviewers are 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement and prospective authorization and coverage for the Zoll Life Vest wearable cardioverter defibrillator for treatment of the enrollees ST-elevation myocardial infarction (STEMI) status post percutaneous coronary intervention (PCI) to proximal mid left anterior descending (LAD) artery with one drug eluting stent.  Findings:  The physician reviewers found that there is potential for recovery of LV function over time after revascularization and with medical therapy. There was no indication for immediate placement of a defibrillator such as sustained or inducible ventricular tachycardia, syncope or aborted sudden cardiac arrest. Placement of a prophylactic defibrillator is not recommended until at least three months have elapsed where continued LVEF of 35% or less is documented to persist despite appropriate treatment. A prophylactic defibrillator (wearable or implantable) before this time has not been demonstrated to improve health outcomes. Also, studies evaluating wearable defibrillators during periods of increased risk where criteria for implantable defibrillators have not yet been met are largely comprised of registry data without adequate control groups. Final Result: All three reviewers determined that the device at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Otezla for treatment of the enrollees psoriasis. Findings:  The physician reviewer found that records do not document a contraindication to the use of methotrexate, cyclosporine, or acitretin, and failure or contraindication to treatment with Enbrel and Humira. The patinet's past positive PPD does not appear to represent active or latent tuberculosis disease given his recent negative QuantiFERON Gold tuberculosis testing. The medical records indicate that the patient may be considered for treatment with Cosentyx, another injectable biologic agent, demonstrating that usage of biologics would not be contraindicated in 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 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

An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as heterogeneously dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: All 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the cooling device for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the limited evidence currently available was insufficient to draw definitive conclusions on the effective of cryotherapy for outcomes other than immediate postoperative pain reduction compared to no cryotherapy. There was a need for well-designed, good quality randomized trials to answer other questions related to this intervention. This patient underwent left knee arthroscopic surgery for a diagnosis of medial meniscus tear, positive lateral meniscus tear, and subchondral cyst.  There is support for the use of cryotherapy in the immediate postoperative period following knee surgery.  However, there is a lack of large volume, long-term studies evidencing significant overall outcome differences with regards to continuous flow cryotherapy versus standard cold packs, for knee arthroscopic surgeries. Final Result: Two of three reviewers determined that the device 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 number one, two, and three are board certified in orthopedic surgery and actively practicing. The reviewers are an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. 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: Two of the 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: Physician reviewers number one, two, and three 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 medical condition. Findings:  The physician reviewer found that the American College of Radiology (ACR) has urged tomosynthesis be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms. 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: Two of 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: Physician reviewers number one, two, and three 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 reimbursement for partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the patient showed no post-acute withdrawal symptoms. He was medically stable. the patient was cognitively intact and able to provide for his activities of daily living. With the exception of isolated occurrences the patient was compliant with the patient's medication and treatment regimens. The patient had episodic outbursts of anger in which the patient punched walls, slammed doors and used profanity. These episodes were not directed at others, only at inanimate objects, therefore the patient is not considered to be a danger to others. The patient denied suicidal or homicidal ideation. The patient was stable on a medication regimen and Trileptal was added later in the admission, which was tolerated well. The patient had plateaued with respect to any significant change in behavior. Although the patient had obtained and sponsor and employment, no major behavioral changes occurred in treatment course after that period of time. The gains made, such as higher compliance with treatment planning, could have been achieved on an outpatient basis. Since his family situation was not optimal, a community based support system could have been developed along with 12-step meetings. Final Result: The reviewer determined that a portion of the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an epidural injection for treatment of the enrollees medical condition.  Findings:  The physician reviewers found that there is a lack of support for the requested services in this clinical setting.  There is a paucity of information published on the use of epidural steroids in the thoracic spine.  Further, the patient has compression of the thoracic spinal cord.  Administration of liquid into the thoracic epidural space may lead to further compression of the spinal cord.  The standard of care here is an open decompression procedure, not an epidural steroid injection which will increase pressure in the epidural space and may further compromise the spinal cord. Final Result: Two of three reviewers determined that the requested services are 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 number one, two, and three are board certified in anesthesiology with sub-specialty certification in pain medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for advanced lipoprotein testing for evaluation of the enrollees medical condition.   Findings:  The physician reviewer found that 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 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein (a), C-reactive protein, insulin, insulin resistance testing, 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.  Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Final Result: All 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and are actively practicing. The reviewer 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 Praluent 75 mg/mL pen injector. Findings:  The physician reviewer found that Praluent is a PCSK9 inhibitor approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL-cholesterol. The documentation does not support that the patient has either condition. Specifically the Dutch lipid criteria for heterozygous familial hyperlipidemia is not met. Familial hypercholesterolemia usually manifests by a combination of physical exam findings which are not present in this patient, LDL-cholesterol levels that are usually significantly higher than this patients level of 188 mg/dl, genetic confirmation that is not documented, and a personal history of premature vascular disease, which also is not documented. In addition, PCSK9 inhibitors have not been studied in other patient populations such as this case. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Finally, there are other statin medications such as pitavastatin and fluvastatin that have lower side effect profiles and have not been documented to be tried or not tolerated in 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial hair removal for treatment of the enrollees gender dysphoria.  Findings: The physician reviewer found that the requested services are medically indicated in this clinical setting. Facial hair removal is within accepted standards of practice and clinically appropriate for treatment of gender dysphoria. Facial hair in a female would be considered abnormal and is referred to hirsutism. The abnormal hair is congenital, in that the hair growth is determined by the genetic and hormonal make-up of the patient. The requested facial hair removal can provide substantial improvement in the appearance of terminal hair and create as normal an appearance as possible. Moreover, the requested services are going to improve emotional function for this patient. These treatments will create a more feminine facial appearance. Therefore, the requested facial hair removal is medically necessary. For the reasons stated above, the requested services are reconstructive in nature and are medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services are reconstructive in nature 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient psychiatric hospital services. Findings: The physician reviewer found that although the patient has a severe formal thought disorder that will require long-term specialty care, the records provided for review do not demonstrate the medical necessity for services at the acute inpatient level of care during the disputed timeframe. Per psychiatry notes, the patient was tolerating her psychotropic medication which consisted of both an antipsychotic and antidepressant. The patients mood was good, her thought process was goal directed, and she had no suicidal ideation. She was cognitively intact. She was neither delusional nor psychotic and she was engaged in treatment. Her laboratory monitoring for clozapine therapy was stable, and earlier episodes of bradycardia and orthostatic syncope had resolved. Overall, there is a lack of evidence to suggest that transition to a less restrictive setting would have compromised the patients safety or misaligned with reasonable practice standards. 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 psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.