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

Nature of Statutory Criteria/Case Summary: An enrollee has  requested Daklinza and Sovaldi for treatment of his hepatitis C virus. Findings: The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with life expectancy less than 12 months due to nonliver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi/Daklinza Sovaldi/PEG-interferon and ribavirin. This is based on the ALLY-3 study for Sovaldi/Daklinza and the Boson trial for Sovaldi/PEG-interferon with ribavirin (Nelson, et al; Foster, et al).  However, there is evidence that use of PEG-interferon self-injections can result in recidivism of intravenous drug use (Gigi, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested transcranial magnetic stimulation for treatment of his behavioral health conditions. Findings:  The physician reviewer found that there is a lack of support for the requested services in this patients case.  The record reflects discrepancy with the psychiatric diagnosis.  In a letter dated recently, the provider noted a diagnosis of major depressive disorder.  However, documentation authored by the same provider previously noted a long history consistent with a diagnosis of bipolar disorder, while another provider who has treated the patient for a number of years articulated the diagnosis of bipolar affective disorder in a letter also dated recently.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder.  However, the recommendation does not extend to bipolar disorder.  Although there is some preliminary positivism regarding the application of transcranial magnetic stimulation for bipolar disorder, there is an absence of well-controlled and adequately powered exploratory and confirmatory studies.  In this patients case, the records support the diagnosis of bipolar disorder and not unilateral depressive illness.  The medical evidence has not established that transcranial magnetic stimulation is reasonably expected to improve the patients bipolar illness, while the safety and appropriateness of transcranial magnetic stimulation for this indication remain unclear.  Further, it does not appear that the patient has failed other treatments commonly relied upon to treat bipolar disorder.  For example, the patient has not exhausted polypharmacy.  Additionally, it does not appear that the patient has had an informational consultative appointment with an electroconvulsive therapy specialist to learn more about the treatment, which remains a trusted, rapid and effective intervention for both mania and bipolar depression.  Finally, there was a dearth of information regarding the status of supportive relationships and community functioning, or outcomes of non-pharmacological interventions.  Although the patient had tried psychotherapies in the past, there was no reported outcome of cognitive behavioral therapy and it does not appear that he had trialed other evidence-based therapies for bipolar illness, such as family therapy or interpersonal/social rhythm therapy.  All told, transcranial magnetic stimulation is not medically necessary 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks, increase in detection of small cancers and decrease in biopsies, especially in women with extremely or heterogeneously dense tissue.  In sum, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a transcranial magnetic stimulation (Spring TMS) device for the treatment of her medical condition. Findings:  Three physician reviewers found that review of the submitted documentation and relevant literature supports the use of the Spring TMS device in this clinical setting. The Spring TMS device is U.S. Food and Drug Administration (FDA) approved treatment for chronic migraine. The study by Weatherall and colleagues evaluated patient response to the Spring TMS device. The authors found that 73% of patients prescribed the device reported partial or complete pain relief, 53% reported a reduction in the number of headache days, 63% reported a reduction in non-pain migraine symptoms, and 17% reported improved sleep quality. These improvements continued throughout and beyond the three-month study period. Given the support in the peer-reviewed literature, the Spring TMS device was likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the device 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 reviewers are board certified in neurology 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 inpatient mental health services for treatment of her behavioral health condition.  Findings:  The physician reviewer found that the documentation submitted for review does not support the medical necessity of the inpatient mental health services in dispute. Initially, the patient was anxious, angry and depressed. Despite her distress, there was no mention of cognitive impairment, psychosis or suicidal ideation. There were no significant medication changes as she continued on quetiapine and sertraline. The records do not include a thorough mental status examination and there was no assessment of the patients risk for suicide. There was no treatment plan. There was no interpretative summary articulating the need for service delivery at the inpatient setting as opposed to a less restrictive level of care. In sum, the record does not demonstrate the presence of an acute psychiatric syndrome or medical crisis. Thus, the inpatient mental health services in dispute were not and are not medically necessary for treatment of the patients behavioral health condition. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  This patient was severely ill when she was admitted to the hospital with a psychotic mania.  She had already been treated at an acute level followed by residential level of care, without improvement.  This was a complicated clinical presentation, as the patient did not respond to medication and treatment in the usual way.  Although her symptoms were subsequently well controlled, she was experiencing important side effects of hypersalivation, muscle rigidity and muscle stiffness.  The provider determined that the patient needed a reduction in the dosage of her medications to address these issues.  However, given her treatment history, reducing her medication came with a significant risk of relapse.  Therefore, it was prudent and medically necessary to begin this medication reduction while she was still in hospital and could be closely observed.  Eventually, she tolerated the changes and was showing a decrease in side effects.  Therefore, plans could have been made to safely discharge her home.  All told, inpatient psychiatric hospitalization was initially medically necessary, but not thereafter. Final Result: The reviewer determined that a portion of the services at issue was 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 with sub-specialty certification in child and adolescent 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a lumbar medial branch block for treatment of her medical condition.  Findings:  The physician reviewer found that this patient has physical exam findings, pain complaints and diagnostic imaging which are all concordant for lumbar facet arthropathy. The MRI and prior treatments have been aimed at axial and lumbar radicular pain and she has not responded adequately. Facet medial branch blocks are an appropriate next step given her findings on exam and on imaging. Thus, the requested for lumbar medial branch block is 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 reviewer is board certified in anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Butrans for the treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  The current standard of care for chronic pain syndrome is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain.  Baron and McDonald reported that high-dose opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high-dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia.  There is a lack of support for the requested medication in this clinical setting.  All told, Butrans is not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in anesthesiology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested continued skilled nursing for treatment of his medical condition. Findings:  The physician reviewer found that based on the clinical documentation submitted for review, the medical necessity for skilled nursing services has not been established. In this case, the patient has requested continued skilled nursing services after a stroke. His functional mobility, self-care, communication, and swallowing are profoundly affected. The patient has been treated with intensive inpatient rehabilitation services and continues to require tube feedings, and is dependent for mobility and self-care. The patient sustained a stroke, and his pace of recovery will be slower now than closer to the time of stroke. He has made minimal progress thus far. Further significant functional improvement with inpatient therapies is not likely. In addition, skilled nursing services are not supported by the medical literature or by the patients recovery trajectory. All told, continued skilled nursing services were not and are not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

 Nature of Statutory Criteria/Case Summary: An enrollee has requested a pelvic and abdominal ultrasound for evaluation of her medical condition.  Findings:  The physician reviewer found that the ultrasound examination was recommended for evaluation of severe pelvic pain. According to the American Institute of Ultrasound Medicine (AIUM), pelvic pain is an accepted indication for ultrasound evaluation. Bhavsar and colleagues noted that for non-pregnant women with pelvic pain, ultrasonography or computed tomography is indicated, depending on the possible diagnosis. The authors further noted that ultrasonography is preferred when ovarian pathology is suspected. Consistent with these findings, the requested pelvic and abdominal ultrasound is supported as medically necessary for evaluation of this patients pelvic pain.  Final Result: The reviewer determined that the requested diagnostic procedures are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  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.  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.  Thus, breast tomosynthesis was likely to have been more effective than other methods for evaluating this patient. 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.   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.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  In sum, breast tomosynthesis was 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. According to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. Moreover, there is sufficient support in the peer-reviewed literature for the use of tomosynthesis in this clinical setting. Therefore, the services at issue were 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 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.