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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis performed for the enrollee, who presented for a breast examination.  Findings:  The 3 physician reviewers found that the patient is a female who is asymptomatic with respect to her breasts.  The patient reported that she does not have a history of breast cancer. In addition, she has had prior augmentation mammoplasty. Her breast tissue was described very dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed. Per the Health Plan, the service at issue was investigational for the evaluation of this patient.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 scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, the presence of breast implants is not, in itself, an indication for tomosynthesis. As was noted for this patient, it is important to obtain implant displacement views so that the native breast tissue was better separated from the potentially obscuring implants.  It was noted, however, that her breast tissue was very dense.  It is specifically those patients, who have dense breast tissue that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. This has been shown to be most useful in the evaluation of dense breasts. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 3 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for psychiatric emergency services. Findings:  The physician reviewer found in this case, the patient was experiencing a recurrence of a previously established mental illness. There was no mention of an acute psychiatric syndrome such as suicidality, homicidal ideation, mania, psychosis or grave disability. Further, the patient was not being treated at the time which is significant as it appears that he previously did well on pro-serotonergic medication and had not optimized evidence-based treatments typically delivered in the outpatient setting.  Although often recurrent and debilitating in nature, OCD is not a life-threatening medical emergency. When a patient with OCD has a co-occurring acute psychiatric syndrome, the combination may result in an emergent condition necessitating specialty services from an emergency department or an acute inpatient psychiatric unit. However, the patient in this case was treated at the partial hospital level of care, which does not ordinarily provide emergency care. Moreover, a common exclusionary criterion for partial hospitalization is the presence of a psychiatric emergent condition. Thus, the patient did not receive psychiatric emergency medical services on the dates of service at issue. Final Result: The reviewer determined that the patient did not receive psychiatric emergency medical services on the dates of service at issue. 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 reimbursement for the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings:  2/3 of the physician reviewers found that the patient is asymptomatic with respect to her breasts. She has a family history of breast cancer, and a cousin. In addition, the patient has had a prior core biopsy of her right breast, which was benign. She also has had a prior augmentation mammoplasty. She underwent a routine screening mammogram consisting of a three-dimensional (3D) tomosynthesis study with synthetically reconstructed two-dimensional (2D) views. In addition of routine views, implant displacement views were also obtained. The current images were compared to prior mammograms and no interval changes were noted. There were no masses, areas of suspicious calcifications, or areas of architectural distortion. Her breasts were described as heterogeneously dense. The patient has requested reimbursement for the digital breast tomosynthesis performed. The Health Plan has denied this request as investigational. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously 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. Accordingly, the digital breast tomosynthesis performed was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: The 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: Physician reviewer number one is board certified in diagnostic radiology 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.Physician reviewer number two is board certified in diagnostic radiology 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.Physician reviewer number three is board certified in diagnostic radiology 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 reimbursement for the blood test, advanced lipoprotein testing for evaluation of the enrollee, who presented with heart palpitations.  Findings:  The physician reviewers found that The patient no prior history of heart disease. She presented with four to five week history of intermittent palpitations and anxiety. Her blood pressure, pulse and cardiopulmonary examinations were normal. The patients resting electrocardiogram (EKG) was also normal. The patients provider referred the patient for blood testing including chemistries, standard lipids profiles, advanced lipoprotein studies and advanced coagulation and metabolic studies.  Per the Health Plan, the services at issue were investigational for the evaluation of this patient. The medical literature does not support the superior efficacy of the services at issue in this clinical setting. The records did not indicate that this patient has a history of coronary artery disease. There were no other significant risk factors for cardiovascular disease. Based on her young age, female gender, and relatively normal cholesterol levels, normal blood pressure and no other risk factors for cardiovascular disease, her calculated risk of heart disease or stroke over the next ten years is extremely low (0.1%). She has had recent intermittent palpitations associated with anxiety and stress but no symptoms of angina, shortness of breath or other symptoms of obstructive cardiovascular disease which would be associated with elevated lipids. The patient also has no indication for pharmacologic therapy for cholesterol reduction based on her symptoms or a standard risk profile. In this instance, the patients standard risk profile is extremely low and the symptoms (intermittent palpitations associated with stress) are also not consistent with obstructive cardiovascular disease. Therefore, the advanced lipoprotein testing was not likely to be more beneficial than the standard evaluation of risk of heart disease in this patient. Final Result: All three reviewers determined that the services at issue were not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in cardiovascular disease and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for non-emergency medical transportation for treatment of the enrollee, who has been diagnosed with end stage renal disease.Findings:  The physician reviewer found that the patient is able to ambulate independently and is independent with his own activities of daily living.  The records indicate that he is medically stable.  He has family support that assists with transportation to and from dialysis.  The documentation does not support that the patient is unable to arrange alternative transportation.  Therefore, non-emergency medical transportation is not medically indicated 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 internal 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: The parent of an enrollee has requested authorization and coverage for Alimentum formula along with PediaSure for treatment of the enrollees medical condition. Findings:  The physician reviewer found that records provided for review document that this patient is dependent upon formula for her nutrition. She has multiple food allergies and oral intolerance, requiring a specific blend of PediaSure and Alimentum to meet her needs. While Alimuentum is not typically considered to be a toddler formula, in combination with PediaSure, which is an age appropriate formula, can provide the nutritional balance that this patient requires. Until she is able to tolerate purees and other foods by mouth in sufficient quantity to allow for growth and development, PediaSure and Alimentum are both medically necessary for treatment of this patients medical conditionFinal Result: The reviewer determined that the requested products 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 pediatrics with sub-specialty certification in pediatric critical care 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 authorization and coverage for opioid pain medication for treatment of his chronic low back pain. Findings:  The physician reviewer found that chronic pain that is unable to be cured can be considered palliative in nature and treatment. The stepwise World Health Organization (WHO) ladder for pain relief is considered the reasonable approach to pain control in the palliative setting. However, in this patients case, not all non-opioid treatment options have been optimized or tried. Also, behavior therapy was discussed but not completed despite much research to support its use. Medical literature have shown that continuation of prescribing opioid medications, at higher doses, without proper treatment for the drug use, sets the patient up for higher morbidity and mortality. Moreover, the medical evidence supports consideration of alternatives to opioids and to plan for patients to taper off opioids. In addition, any continuation of opioid medication should be under the direct guidance of a mental health professional, given some documentation that this patient had taken someone elses pain medication. Finally, there was no clear objective functional goals for the additional opioids being requested and there was no evidence provided for using long acting opioids before exhausting the use of short acting opioids. There is sufficient support to offer interventional treatments for this patient's pain. For the reasons stated above, the requested opioid pain medication is not medically necessary for 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 authorization and coverage for Epclusa for 24 weeks for treatment of the enrollees hepatitis C virus genotype 1b.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 non-liver-related conditions. However, the AASLD/IDSA guidelines state that patients who fail an NS5A inhibitor such as Harvoni should have testing for NS5A and NS3 resistance-associated variants and these are not provided. The guidelines also state that patients who fail an NS5A inhibitor such as Harvoni should be treated with a 24-week regimen, and that ribavirin should also be included in all cases, based on clinical studies. Epclusa is never recommended without ribavirin after failure of an NS5A inhibitor such as Harvoni. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for surgery to remove the Nuss bar.Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested surgery. Removal of the pectus Nuss bar is medically necessary. In addition, the original provider should be the one who removes the Nuss bar, as complications can occur including the need to free the bar from embedded bone and the need for possible bilateral dissection. Given that four years have passed since the original surgery, the likelihood of bone ingrowth and the need for further dissection supports the original provider as likely to be best suited to perform the removal procedure. Final Result: The reviewer determined that the requested surgery 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 thoracic 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Ensure three times per day. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested product.  Weight loss in patients with human immunodeficiency (HIV) infection is usually episodic, occurring with secondary infections or gastrointestinal diseases.  Patients with anorexia-cachexia syndrome who are able to eat should be recommended to have small, frequent meals that are dense in calories.  In this case, the documentation does not support that the patient has had a clinically significant loss of weight.  The office note documented that the patients HIV infection was well-controlled.  There is no documentation of any secondary infections.  The patient does have a laryngeal prosthesis with persistent fistula and dysphagia.  The documentation does not indicate the patient has failed treatment with alternative food consistencies or has had a loss of appetite. Final Result: The reviewer determined that the requested product is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in internal medicine 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 female enrollee has requested authorization and coverage for Zepatier 50 -100 mg for treatment of the enrollees hepatitis C. Findings:  The physician reviewer found that according to the most recent 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 limited life expectancy due to non-liver-related conditions.  The guidelines state that patients with cirrhosis are high priority for treatment, and that cirrhotic, treatment-naive, genotype 1 patients should be treated with Harvoni for 12 weeks or Zepatier for 12 weeks.  Both medications are U.S. Food and Drug Administration (FDA) approved for patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage, and have proven highly effective. The guidelines recommend either Harvoni or Zepatier as acceptable therapy.  NS5A resistance testing is negative in this case, as recommended prior to Zepatier use in genotype 1a.  However, the guidelines do state that Harvoni should not be used in patients taking omeprazole at a dose of higher than 20 mg daily.  In this case, the patient reportedly cannot decrease the dose of omeprazole 20 mg twice daily, and decrease in omeprazole may result in vomiting that could cause pill loss and treatment interruption or failure.  For these reasons, Zepatier 50 - 100 mg is medically indicated for the 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: 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.