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 status post right mastectomy. 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 likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are 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 mastectomy for gynecomastia for treatment of the enrollees gynecomastia.  Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  Overall, there is insufficient documentation to justify bilateral mastectomy for gynecomastia.  The documentation from the requesting surgeon does not contain a detailed breast examination.  In addition, the patients weight gain may be a contributing factor, and consideration should be given for a weight loss trial prior to any surgical intervention.  The patients pain and discomfort is not adequately supported in the medical documentation as likely due to distention and tightness from hypertrophied breast.  In addition, the patient appears to only have a relatively mild degree of enlargement, grade I/II in severity.  There does not appear to be a concern for possible malignancy based on examination detail and mammogram results.  Based on the available documentation, the requested mastectomy for gynecomastia is not medically necessary for the treatment of this patient.  In this patients case, there is insufficient documentation that the current condition is significantly abnormal.  The photographs do not show a condition that is significantly abnormal, and it is unclear the degree of the condition related to his documented weight gain.  There is a lack of documentation demonstrating that the requested services will result in improvement in function or create a normal appearance.  In sum, mastectomy for gynecomastia is not reconstructive in nature and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are not reconstructive in nature 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 plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 60 Percocet every month for treatment of the enrollees chronic neck/back pain, and migraines. Findings:  The physician reviewer found that the submitted documentation supports the requested medication for treatment of this patient. Percocet is an analgesic, taken as needed, for the treatment of moderate to severe chronic pain. The patients medical record demonstrates a history of chronic back and neck pain.  This patient endorses analgesia with Percocet and denies adverse side effects. The patient reports improvement in his activities of daily living when on this medication. The patient reported that he has tried and failed other therapies for the treatment of his pain, and Percocet was the most effective. Sixty tablets of Percocet every month is well within the normal standard prescribed for this medication. The medication can be taken twice per day, thus for a 30 day period of time, a prescription for 60 tablets is medically appropriate. The medical literature supports 60 tablets as a low dose regimen and would not be considered a large quantity of medication dispensed on a monthly basis. Furthermore, the records did not indicate that the patient displayed aberrant behavior while on this medication. As such, the requested medication is medically appropriate for treatment of this patients chronic pain. 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: The reviewer is board certified in anesthesiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for partial hospitalization program (PHP) services and intensive outpatient program (IOP) services for treatment of the enrollees alcohol dependence. Findings:  The physician reviewer found that the patient denied post-acute withdrawal symptoms. The patient  was not a danger to himself or others. He was medically and psychiatrically stable. There were no emotional, behavioral, or cognitive barriers to treatment at a lower level of care. The patient was motivated and demonstrated insight. The patients spouse was supportive of treatment. The patient did not require the intensive treatment of PHP with five days per week contact. In addition,the patient had continued to maintain abstinence since his last use and did not require treatment at the IOP level of care. The patient was engaged in his recovery process and could have been stepped down to an outpatient level of care, with ongoing counseling and community support in the form of AA. The patient no longer required the structure of IOP services. 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 with sub-specialty certification in addiction medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollee's risk of breast cancer. 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 patients case, though asymptomatic, her breast tissue was described as extremely dense.  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.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other methods of evaluating this patient.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 breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three-dimensional digital breast tomosynthesis to two-dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three-dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.Final Result: Two physician reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Credentials/Qualifications: All three physician reviewers are 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 Xeljanz for treatment of the enrollees alopecia universalis.  Findings: Two physician reviewers found that Alopecia areata (AA) is a chronic immunological disorder characterized by round or oval patches of non-scarring hair loss. Alopecia universalis is a form of AA including eyebrows, eyelashes and facial hair. Treatment is challenging and aims at the regrowth of hair. AA causes dramatic and devastating emotions in patients, which can negatively impact their self-esteem, body image, and/or self-confidence. The experience of alopecia is psychologically harmful and can result in emotional distress. Xeljanz (tofacitinib) is an oral JAK inhibitor approved for the treatment of moderate to severe rheumatoid arthritis. Xeljanz has also been studied for treatment of psoriasis, inflammatory bowel disease, and other immunological diseases. Several recent reports in the medical literature demonstrate the effectiveness of tofacitinib in the treatment of AA (Jabbari, et al; Gupta, et al). Given the support in the peer-reviewed literature, Xeljanz is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the requested medication 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 dermatology 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 digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer. Findings: Three 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, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested water circulating cold pad with pump (HCPCS-E0218) used post-operatively for treatment of the enrollees medical condition status post left shoulder surgery.  Findings: Two physician reviewers found that the water circulating cold pad with pump was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Uquillas and colleagues reported on various means of controlling pain after a shoulder surgery. The authors indicate that cryotherapy can be effective, however they failed to conclude that cryotherapy is superior to other standard methods. Kraeutler and colleagues compared cryotherapy with the standard therapy of ice wrap. The authors concluded that There does not appear to be a significant benefit to use of [compressive cryotherapy] CC over standard [ice wrap] IW in patients undergoing shoulder arthroscopy for rotator cuff repair or subacromial decompression. In sum, there is a lack of medical literature supporting that the post-operative use of water circulating cold pad is superior to standard therapy such as an ice wrap. Therefore, the device at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.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 board certified in physical medicine and rehabilitation 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 inpatient detoxification services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that although inpatient detoxification services were indicated, the medical record does not demonstrate the necessity of the inpatient level of care for detoxification.   Despite the concerning report of delirium tremens and seizure, the patient had no prior clinical treatment for withdrawal. During the hospital stay, he was treated with a chlordiazepoxide taper. The records show that two days subsequent to the patients last use of medication for withdrawal symptoms, the patients vital signs were stable and his mental status examination was reassuring. The patient was not psychiatrically distressed. His laboratory studies were essentially normal. Aside from chronic shoulder pain, he had no medical complaints. Per the nursing notes, his gait was steady and he was not depressed. The patient was active in treatment; he led at a 12-step meeting on the unit. He was motivated and optimistic. His wife was supportive and he wanted to continue chemical dependency treatment. In sum, the record does not reflect that chemical dependency services provided in a less restrictive setting would have been inadequate. Therefore, the inpatient detoxification services were not medically necessary for treatment of the patients medical condition.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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensity modulated radiation therapy (IMRT) for treatment of the enrollees prostate cancer. The Health Plan has denied this request indicating that the services at issue were considered investigational. Findings: Two physician reviewers found that IMRT is a tool that providers can use when there is concern about sparing normal tissues from high dose exposure. IMRT generally implies inverse planning algorithms which helps maximize dose to the target and minimize dose to normal tissues, and the planning algorithm maximizes the adherence to these parameters by modifying the beam spatially and/or temporally. Usually, multiple fields are delivered. Radiation therapy after prostatectomy is recommended for patients with high risk features and/or rising PSA in the absence of metastatic disease. A recent study showed that with IMRT, there is no increased toxicity of treating the pelvis versus the prostate bed (Jereczek-Fossa, et al). In addition, the American Urological Association (AUA) and American Society of Radiation Oncology (ASTRO) guidelines indicate that for some anatomical sites such as the prostate, IMRT should be considered the standard of care (Thompson, et al). Consistent with this support, IMRT was the most safe and effective way to treat this patient to close to 70 Gy radiation. The rectum and bladder are in close proximity to the target. In general, the radiation field for the pelvis after prostatectomy is a concave treatment volume around normal structures, for which IMRT is much better suited to conform to, as opposed to conventional conformal radiation. Thus, the IMRT treatments were likely to have been more beneficial for treatment of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were 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 radiation oncology 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 the medication, growth hormone for treatment of the enrollees infertility. Findings:  The physician reviewers found that in this case, the patient did not demonstrate a history of being a poor responder to IVF therapy, and the growth hormone appeared to have been used as a routine adjuvant. Such use is not supported by the medical literature to date and should be considered investigational. Therefore, the medication, growth hormone was not likely to be superior to available standard therapy for the treatment of the patients infertility. Final Result: All three reviewers determined that the medication 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 obstetrics and gynecology with sub-specialty in reproductive endocrinology/infertility 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.