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

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees 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. In this particular patient, there were multiple reasonable indications for digital breast tomosynthesis. The presence of calcifications, the multiple masses, and the considerable scarring supported the use of digital breast tomosynthesis to separate the overlying breast tissue. Ordinarily, a repeat digital breast tomosynthesis would not be warranted after such a brief interval.  However, the issues presented in this patients case required the use of digital breast tomosynthesis in order to evaluate for malignancy. Therefore, in light of the records, the digital breast tomosynthesis used in the examinations were likely to have been more effective than other methods of evaluating this patient for breast cancer.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested  intravenous immunoglobulin (IVIG) replacement therapy for treatment of the enrollees common variable immunodeficiency (CVID).  Findings: The physician reviewer found that, in this case, the patients presentation is not consistent with hypogammaglobulinemia or CVID, only IgG subclass deficiency with a normal total IgG and a slightly low IgA and asthma. Although the records refer to recurrent infections, there is a lack of supporting documentation such as chest x-ray, computed tomography (CT) chest scans, or CT sinus scans to confirm this. In addition, the patients laboratory tests do not substantiate a history of recurrent severe sinopulmonary infections or other opportunistic infections seen with a primary antibody deficiency (Bonilla, et al). The records provided do not clearly evaluate the patients ability to respond to infections as required for the diagnosis of CVID (Ballow). The patient is reported to have a low diphtheria titer, but it is unclear if she has been revaccinated to test her immune response to protein. There is also no documentation of a trial of prophylactic antibiotics or other therapies tried and failed such as aggressive allergic rhinitis treatment or vaccination with conjugate pneumococcal vaccine. The diagnosis of CVID requires a significantly reduced total serum concentrations of IgG, low IgA and/or immunoglobulin M (IgM), poor or absent response to immunization and exclusion of other immunodeficiency states or causes. In this case, the patient is reported to have low IgG subclasses and IgA but normal total IgG and IgM, but none of the other criteria of CVID (Chapel, et al). Further, the treatment of subclass deficiency with a normal total IgG with replacement IVIG remains controversial. Most experts recommend treatment which includes immunization with conjugated pneumococcal vaccine, aggressive treatment of other conditions predisposing to recurrent sinopulmonary infections, appropriate antibiotic therapy for infections, and prophylactic antibiotics. Given these findings, the request for IVIG replacement therapy is not medically necessary for treatment of this patients medical condition.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 with sub-specialty certification in rheumatology and allergy and immunology 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 custom molded foot orthotics for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested equipment.  According to standard of care guidelines, orthotics are indicated for patients with diabetes and risk factors associated with their feet.  Furthermore, orthotics may be recommended if they are an integral part of an orthopedic shoe, brace, or prosthesis.  There is no indication that either of these criteria are met in this patients case.  The Health Plans criteria are medically appropriate.  The current medical evidence does not support the requested equipment in this clinical setting.  Therefore, the requested custom molded foot orthotics are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested equipment is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The physician reviewer is board certified in podiatry 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: A enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement in 2014. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. 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 is 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 acute inpatient mental health treatment for the enrollees behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  During the dates of service in dispute, the patient was not a danger to herself or to others.  The patient was not impulsive or aggressive.  The patient was medically stable.  Her mood was euthymic, and her speech was logical and goal directed.  She remained anxious and apprehensive, but this did not require inpatient level of care.  The patient was episodically disorganized, but was no longer delusional, psychotic, manic, or impulsive.  The patient was tolerating her medications without side effects.  Her activities of daily living had improved.  All told, acute inpatient mental health treatment from the health plan's date of denial forward were not and are not medically indicated for the treatment of this patient.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 physician 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees hepatitis C. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  According to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  The guidelines recommend that non-cirrhotic, treatment-naive, genotype 1b patients should be treated with Harvoni for 12 weeks.  These recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage.  Zepatier for 12 weeks is also a recommended regimen, and the guidelines recommend either as acceptable therapy.  Thus, the Health Plans alternative Zepatier is medically appropriate for the treatment of this patient.  Therefore, the medical necessity of Harvoni 90-400 mg has not been established.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 physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for RT300 functional electrical stimulation (FES) cycle therapy system for treatment of the enrollees medical condition. Findings:  The physician reviewers found that the requested device is not likely to be more efficacious than other treatment options, such as resistance-based circuit training, wheelchair ergometry or arm cranking ergometry.  Patients with spinal cord dysfunction have reduced aerobic capacity, increased incidence of being overweight, and reduced upper body strength.  Addressing these issues is of substantial importance to reduce the risk of comorbid medical issues.  Resistance-based circuit training provides cardiorespiratory and strength benefits in people with paraplegia.  There is evidence that upper body resistance circuit training, arm cranking ergometry, wheelchair ergometry, and FES cycling may improve cardiovascular health.  However, there is a lack of robust clinical studies identifying superiority of FES cycling versus the other types of exercise.  Furthermore, in regards to spasticity, there is a lack of studies indicating that FES cycling is superior to standard treatments for spasticity. Final Result: Two of three reviewers determined that the requested device 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 physical medicine and rehabilitation and is 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the services on an emergent basis or urgent basis. Findings:  The physician reviewer found  a prudent layperson would not have sought immediate medical attention. Based on the records provided the patients presentation during the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented with a long history of back pain. There is a lack of clinical documentation demonstrating that the patient presented with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the patients health in serious jeopardy. There is no documentation submitted showing the patients pain rating severity. In addition, acute intervention was not warranted. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would not reasonably believe he was suffering from a serious medical condition. In sum, the patient was not suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services did not meet prudent layperson criteria for emergency care.Further, it has not been established that criteria for urgently needed services were met on the date in dispute. The patient presented with a long history of cervical complaints. The records document multi-level central spinal and neural foraminal stenosis. However, there is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the she returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation during the dates in dispute the patient did not meet prudent layperson criteria for urgently needed services.Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld. 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

An enrollee has requested reimbursement for Botox injections for treatment of the enrollees medical condition. Findings:  The physician reviewers found that there is a lack of evidence based literature to demonstrate the superiority of Botox injections over available standard therapy for treatment of Oddi dysfunction (SOD), type III. The use of Botox injections to address SOD was initially utilized to provide short-term relief of symptoms. However, a prospective randomized blinded sham by controlled one year outcome study showed no correlation between manometric findings and the outcome after sphincterotomy. Moreover, the patients receiving sham therapy had a statistically significantly better outcome than those undergoing biliary or dual sphincterotomy. In this patients case, there was no manometric documentation provided to support a diagnosis of SOD. While Botox has been used on a case by case basis for a host of gastrointestinal disorders, there is a lack of support for its use for the treatment of this patient. The patient derives transient subjective benefit from her Botox administrations but the objective support for this approach is lacking. Final Result: Two of three reviewers determined that the services at issue were 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 gastroenterology 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: Overturned Decision of Health Plan

An enrollee has requested authorization and coverage for oxycodone (OxyContin) 30 mg, one tablet two times a day for treatment of the enrollees medical condition. Findings:  The physician reviewer found that In this patients case, the records show that the patient has tried and failed conservative therapy for treatment of her medical condition. There is documentation of baseline pain, pain score with use of opioids, and functional improvement on the current regimen. The provider also noted that he reviewed the side effects and potentially aberrant drug taking behaviors with the patient. These metrics, coupled with the signed opioid contract and failed trials of more conservative agents, provide clinical support for the requested OxyContin 30 mg one tablet two times a day for treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewer number one 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested V-Go Disposable Insulin Patch Pump for treatment of the enrollees medical condition.  Findings: The physician reviewer found that there is sufficient support for the requested equipment in this patients case.  Diabetic patients with drug use disorder show a higher rate of adverse health outcomes.  These patients experience more frequent and severe health complications, including an increased risk of hospitalization, readmissions and require longer hospital stays.  The prevention and management of substance abuse must be integrated with medical care.  This patient requires insulin for her diabetes.  However, she is not taking her insulin because the insulin syringes are a reminder of her intravenous drug addiction, and she is concerned that the syringes may be a trigger for resumption of drug use.  The V-Go system is an insulin delivery device that is effective and bypasses the need to utilize insulin syringes.  In order to provide the patient with the best treatment, which is insulin, the V-Go system is medically necessary.  The current medical evidence supports the requested equipment in this clinical setting.  All told, the V-Go Disposable Insulin Patch Pump is 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 physician reviewer is board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms, especially in women with dense tissue.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with the two-dimensional technique 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 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.