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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested intensive outpatient program services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  She was able to live in her customary setting, able to maintain employment, and there were no emerging/impending issues regarding safety to the patient.  In addition, her weight and body mass index (BMI) suggested that the patients eating disorder was not particularly clinically significant in terms of major alterations in her baseline vitals.  No new problems arose during the treatment days.  There was no clinical evidence that re-entry into a lower level of care would result in an exacerbation that would necessitate continued intensive outpatient program level of care, or that less intensive treatment would be insufficient to prevent clinical deterioration.  She was not a danger to herself or others.  She was medically and psychiatrically stable.  She had improved and no longer required treatment at intensive outpatient program level of care during the dates of service in dispute.  In sum, intensive outpatient program services were not medically indicated for the treatment of this patient.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested genetic testing for evaluation of her medical condition.  Findings:  Three physician reviewers found that there is a lack of support for the services at issue in this patients case.  It was then noted that the patient was taking a specific dosage of a prescribed medicine, was previously taking the same medication at a greater dosage and did much better.  She noted her depression did not feel well controlled.  It was noted that the patient had been weaned off of the prescribed medication, and she still had anxiety.  There is support for the use of MTHFR testing for prescribing carbamazepine, tetrabenazine, eliglustat, Ziagen, and Olysio.  These medications are not indicated for anxiety disorders.  In this patients case, switching to another medication did not require this specialized testing.  In sum, genetic testing was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in psychiatry 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 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, providers can better detect abnormalities. Tomosynthesis is rapidly becoming a standard tool in well equipped, respected radiology practices. The problem of evaluating dense breasts or suspicious calcifications is a huge issue for providers. Whenever there are multiple superimposed structures in any organ, imaging that organ with multiple sections (similar to a CT scan), makes sense when those superimposed structures can be better separated and delineated. Tomosynthesis is better than breast sonography as a screening tool, and should lessen the requests for breast magnetic resonance imaging (MRI). For these reasons, breast tomosynthesis was likely to be more beneficial for evaluation of this 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. 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 bilateral breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that despite the lack of long-term results proving an increased survival rate when tomosynthesis has been used in addition to two-dimensional (2D) imaging, the American College of Radiology (ACR) has urged the technique be removed from the investigational due to the advantages it brings to radiologists interpreting mammograms. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in callbacks, increase in accuracy and increase in detection of small cancers. Thus the addition of tomosynthesis to the usual 2D protocol was likely of greater benefit to the patient than had her exam been done with 2D technique. Given that her screening exam included tomosynthesis, spot compression views using a standard approach would have yielded the same information.  For this reason the inclusion of tomosynthesis as part of the unilateral diagnostic study performed subsequent to the initial screening exam was not likely to have been of greater benefit to the patient than conventional work-up.  Final Result: Two reviewers determined that a portion 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 partially overturned.Credentials/Qualifications: All three physician 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 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, by separating the various layers of breast tissue, one can better detect abnormalities. Specifically, 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. All told, in this clinical setting, the use of the digital 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. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three Physician 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: Two physician reviewers found that the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. 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) has urged the technique be removed from the investigational category due to the advantages it brings radiologists interpreting mammograms especially in women with heterogeneously and extremely dense tissue such as in this case. Tomosynthesis allows the radiologist to separate dense glandular elements from underlying mass/architectural distortion resulting in a decrease in biopsies, callbacks and increase in detection of small cancers. Thus, the inclusion of tomosynthesis as part of this patients screening mammogram was likely of greater benefit to the patient than had the exam been done with two-dimensional technique alone.  Final Result: Two 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. 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 abdominoplasty and panniculectomy for treatment of her medical condition. Findings: The physician reviewer found that based on the medical documentation provided for this review, the requested abdominoplasty and panniculectomy should be considered cosmetic interventions for treatment of this patients excess skin. The patient is noted to have a panniculectomy with panniculitis on examination. However, the degree of severity is not detailed and conservative management has not been documented. The patient does have evidence of abdominal pain, but this does not appear to be directly related to the pannus, but more likely associated with the umbilical hernia or other non-specified condition. The photographs provided do not confer a significant condition of the upper abdomen. From the definition of reconstructive surgery from the American Society of Plastic Surgeons (ASPS), reconstructive surgery can be indicated to obtain a more normal appearance. However, in this case the degree of severity is not well-defined, thus the requested surgical intervention is not medically necessary to approximate a more normal appearance. Reconstructive surgery is performed on abnormal structures of the body, caused by congenital defects, developmental abnormalities, trauma, infection, tumors, or disease. It is generally performed to improve function, but may also be done to approximate a normal appearance. Without greater detail from the medical documentation, in regards to the severity of the appearance, the requested surgery is not requested to approximate a more normal appearance. The photographs do not support that the patient has a significantly abnormal appearance. There has not been adequate documentation to support that this is a reconstructive procedure. Moreover, there is insufficient evidence that a functional deficit is present that has failed reasonable conservative management. As the degree of severity has not been adequately documented and that the photographs do not show evidence of clear severity, the requested abdominoplasty and panniculectomy are not reconstructive in nature and not medically necessary.  Final Result: The reviewer determined that the requested surgery is not reconstructive in nature and 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 a neurosurgery consultation for evaluation of his medical condition. Findings: The physician reviewer found that the records provided for review document that this patient does have disc degeneration and scoliotic deformity by history. A consultation with a board certified neurosurgeon is therefore indicated to assess the patient for appropriate non-surgical or surgical treatment options. As noted by Issack and colleagues, nonsurgical management consists of nonsteroidal anti-inflammatory drugs, physical therapy, and epidural steroid injections. If nonsurgical management is unsuccessful and neurologic decline persists or progresses, surgical treatment, most commonly laminectomy, is indicated. Given these findings, the requested neurosurgery consultation is medically necessary for evaluation of this patients medical condition.  Final Result: The reviewer determined that the requested referral is 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 neurological 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting. According to the study by Ciatto and colleagues, the addition of breast tomosynthesis reduces false positives and increases cancer detection when compared to two-dimensional mammography alone. Moreover, 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 (Skaane, et al). Given the support above, the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Two physicians 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. 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.  Therefore, breast tomosynthesis was likely to have been of greater benefit than other modalities 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested or Xeljanz for treatment of her atopic dermatitis.   Findings:  Three physician reviewers found that atopic dermatitis is a common itchy inflammatory skin disease characterized by immune activation, marked epidermal hyperplasia, and defective barrier function, reflecting underlying alterations in keratinocyte differentiation. The disease may be associated with significant morbidity, particularly when complicated by secondary infection. Frequent disruption of sleep is common, and emotional stress associated with the illness can have a significant impact on quality of life for patients and families. Much effort has recently been placed on the development of new treatment strategies for this increasingly common illness. Treatment of atopic dermatitis usually starts with topical agents, such as corticosteroids as well as phototherapy. Skin inflammation in atopic dermatitis results from inherited and acquired insults to the skin barrier, and agents that normalize the skin barrier reduce the dependence on topical steroids. Tacrolimus ointment and pimecrolimus cream are the topical calcineurin inhibitor approved for clinical use and has been demonstrated to be safe and effective in the treatment of patients with atopic dermatitis.  Xeljanz is U.S. Food and Drug Administration (FDA) approved for the treatment of moderate to severe rheumatoid arthritis. In this patient, there is a lack of documentation that standard immunosuppressant medications such as cyclosporine and ultraviolet A (UVA) have been used for treatment. Further, there is no evidence that this patient has been diagnosed with rheumatoid arthritis. Additional studies should confirm Xeljanz efficacy in atopic dermatitis before it can be recommended for treatment of atopic dermatitis patients. Thus, the requested Xeljanz is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the requested medication 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:  All three reviewers are board certified in dermatology 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 breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the American College of Radiology (ACR) recommended that breast tomosynthesis 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. For these reasons, the addition of tomosynthesis to the usual two dimensional (2D) imaging mammographic protocol was likely of more benefit to this patient than if the exam had been performed using 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 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.