Persius/hicric huggingface dataset:
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.  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The addition of digital breast tomosynthesis as part of the screening mammography protocol has gained worldwide acceptance among providers due to an associated decrease in callbacks and increase in detection of small breast cancers.  This improvement is based upon the unique tomographic capability of tomosynthesis which enables radiologists to view the breast in a fashion which largely eliminates the problem of dense overlying glandular tissue. Thus, the addition of tomosynthesis to the usual screening films is likely more beneficial to the patient than digital mammography without added tomosynthesis. 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 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee requested services on an emergent or urgent basis. The physician reviewer found that review of the submitted documentation demonstrates that the patients decision to seek immediate medical attention was consistent with the actions of a prudent layperson. Upon review of the submitted medical records, the patient presented with soft tissue swelling, redness and pain in the right lower eye lid. He was assessed with hordeolum externum and given a prescription for Keflex. In this clinical setting a prudent layperson who was worried that his condition may progress would reasonably believe that the absence of immediate medical attention could result in serious impairment to bodily functions and serious dysfunction of a bodily organ or part. Given that this transpired on a holiday, the patients options for seeking treatment were limited. Based on the patients presenting complaints and symptoms, a prudent layperson in this circumstance would reasonably believe he was suffering from a serious medical condition that required immediate medical attention. Thus, the services meet prudent layperson criteria for emergency care.  Final Result: The reviewer determined the patients symptoms met prudent layperson criteria for emergency care. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in emergency 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 Harvoni for eight weeks for treatment of her hepatitis C virus.  Findings:  Two physician reviewers found that according to the 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related conditions. In treatment-naive genotype 1 patients, therapy is recommended with Harvoni as a Class I, Level A recommendation. These guideline 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. Additionally, treatment of patients before they progress to cirrhosis is advantageous. A prospective study of 820 F0-F1 patients reported 93% 15-year survival in treated F0-F1 patients versus 88% in untreated patients. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, Harvoni is medically necessary for eight weeks in this case.  Final Result: Two reviewers 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: One reviewer is board certified in gastroenterology and is actively practicing.  Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 stem cell transplant, in conjunction with the approved kidney transplant for treatment of his end stage renal disease.   Three physician reviewers found that in this patients case, kidney transplantation as authorized by the Health Plan is clinically indicated. However, there is a lack of adequate evidence to support that an immunosuppressive clinical trial using bone marrow/hematopoietic stem cell transplant (HSCT) in conjunction with the living donor kidney transplant would be more beneficial. The long-term benefit of a living donor kidney transplant utilizing stem cell transplant has not been established to have the best outcome nor has it been proven in the literature as an established transplant practice.  The requested clinical procedure is not the standard of care for patients that undergo kidney transplantation. The risk of opportunistic infections in this patients low risk immunosuppressive protocol living donor kidney transplantation is low. Therefore, based upon the peer-reviewed literature, the requested stem cell transplant, in conjunction with the approved kidney transplant 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 services are 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: One reviewer is board certified in surgery with sub-specialty certification in transplant surgery and is actively practicing. One reviewer is board certified in surgery and critical care surgery with sub-specialty certification in transplant surgery and is actively practicing. One reviewer is board certified in nephrology with sub-specialty certification in renal transplantation and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested for laser therapy for treatment of her medical condition.  The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has had sciatic neuropathy as a complication of hip surgery.  The medical records indicate severe axonal injury, with partial recovery over time. Axonal injuries recover slowly, and patients may take years to reach maximal recovery.  The medical literature does not show significant benefit from laser treatments in humans with sciatic nerve damage, but animal studies show potential benefit.  Human studies of diabetic neuropathy and ulnar neuropathy also show potential for benefit.  Given the lack of other effective treatments, the requested laser therapy is medically indicated for the treatment of this patient. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in neurology 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 prostatic urethral lift implant/urolift (CPT codes 52441 and 52442) for treatment of his medical condition.  Two physician reviewers found that the patient has a presumed diagnosis of benign prostatic hyperplasia.  However, it is unclear whether some of his symptoms are related to benign prostatic hyperplasia.  Distal urethral discomfort and ejaculatory pain are usually not associated with benign prostatic hyperplasia.  His examination reveals a small prostate which is confirmed with an ultrasound.  There is no evidence of elevated post-void residuals suggesting bladder decompensation.  The providers progress notes states that he intends to perform a cystoscopy and urodynamic study to evaluate eligibility for Urolift.  However, the results of both procedures are unavailable for review. In conclusion, there is lack of medical documentation supporting the diagnosis of benign prostatic hyperplasia as the cause of this patients symptoms.  His urinary symptoms could be from bladder neck hypertrophy (which also responds to alpha blockers) or urethral stricture.  All told, the requested prostatic urethral lift implant/urolift (CPT codes 52441 and 52442) is not likely to be of greater benefit than other treatment options. Final Result: Two reviewers determined that the requested services are 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 urology 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 electric tumor treatment fields (TTF) therapy using Optune plus transducers for treatment of the enrollees recurrent glioblastoma multiforme.  Two physician reviewers found that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. The TTF system, which has been approved by the U.S. Food and Drug Administration (FDA), is a portable device that delivers low-intensity, intermediate frequency electric fields via non-invasive means. The study by Stupp and colleagues included more than 200 patients randomized to either TTF or chemotherapy. The authors concluded that there was no difference in progression-free survival, but quality of life and toxicity favored TTF therapy. In addition, the National Comprehensive Cancer Network (NCCN) guidelines include TTF therapy as a treatment option for glioblastoma. Based on the medical literature and clinical documentation submitted, electric TTF therapy using Optune plus transducers 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 services are 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: One reviewer is board certified in medical oncology and is actively practicing. One reviewer is board certified in radiation oncology and is actively practicing.  One reviewer is board certified in neurological surgery and is 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested partial hospitalization level of care for treatment of her bipolar 1 disorder.  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient remained unstable during the period of treatment in dispute.  She was seen by her psychiatrist multiple times each week, and medication adjustments were frequently required.  In addition, she had complex symptoms of paranoia, hallucinations, suicidal and homicidal thoughts, often toward her family members.  It is also important to note that often she developed these symptoms over the weekends when she was not in the structured environment of the partial hospitalization program.  The current medical evidence supports the services at issue in this clinical setting.  All told, partial hospitalization level of care was medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were 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 psychiatry with sub-specialty certification in child and adolescent psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested percutaneous tibial nerve stimulation for treatment of her medical condition. Two physician reviewers found that there is evidence in the peer-reviewed literature from randomized trials and prospective observational trials supporting the clinical utility and impact on patient management of percutaneous tibial nerve stimulation in patients with urinary urgency and frequency.  However, most trials have a small number of patients with short term follow-up.  Percutaneous tibial nerve stimulation is considered a third-line therapy.  In this patients case, the indications for the procedure are unclear.  The patient has no overt symptoms of severe overactive bladder.  The patients voiding diary and urodynamic study do not support the diagnosis.  At this time, there is lack of adequate documentation supporting the diagnosis of refractory overactive bladder needing third-line therapies.  All told, percutaneous tibial nerve stimulation was not and is not likely to be superior over other treatment options. Final Result: Two reviewers determined that the requested services were not and are 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 urology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Viekira Pak and ribavirin for 12 weeks for treatment of her hepatitis C virus. Three physician reviewers found that according to the 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions. For treatment-naive patients, therapy is recommended with Viekira Pak for 12 weeks (Class I, Level A recommendation). Additionally, treatment of patients before they progress to cirrhosis is advantageous. Based on published evidence of safety and efficacy in the published literature, and clinical guidelines, treatment with Viekira Pak and weight-based ribavirin for 12 weeks is medically necessary in this patients case. Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: One reviewer is board certified in gastroenterology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested 12 weeks of Sovaldi and ribavirin for treatment of his hepatitis C virus.  Findings:  Three physician reviewers found that according to the 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, regardless of fibrosis, should be treated except those with limited life expectancy (less than 12 months) due to non-liver-related comorbid conditions (Class I, Level A recommendation). In addition, patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based ribavirin for 12 weeks per AASLD/IDSA guidelines as a Class I, Level A recommendation. Based on evidence of safety and efficacy in the published literature, and clinical guidelines, the requested treatment is medically necessary in this case.  Final Result: Three reviewers determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: One reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. Two reviewers are board certified in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for 12 weeks for treatment of his hepatitis C.  Findings:  Two physician reviewers found that the current medical evidence supports the requested medication in this clinical setting.  Per the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, the medical evidence supports treatment in all patients with chronic hepatitis C, except those with limited life expectancy less than 12 months due to non-liver-related comorbid conditions.  Early initiation of treatment may help avoid untoward complications from advanced disease, including liver failure and extrahepatic manifestations from hepatitis C.  All told, Harvoni for 12 weeks is medically indicated for the treatment of this patient.  Final Result: Two reviewers 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 three reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 left knee decompression including bone marrow aspiration and concentration and injection into lesion (29881, 29887 and 20610) for treatment of her medical condition. Three physician reviewers found that the current medical literature supports the use of joint preserving procedures, including core decompression with concentrated bone marrow cells, for the treatment of secondary avascular necrosis in young patients.  The medical evidence supports joint preservation surgery over total knee replacement for young patients with secondary osteonecrosis of the knee.  This patient has been diagnosed with avascular necrosis of both knees, likely due to corticosteroid use for her chronic Crohns disease.  The records include documentation of a comprehensive nonoperative treatment protocol trial and failure.  She meets the criteria to proceed with joint preservation surgery to treat her secondary osteonecrosis and avoid total knee replacement surgeries.  Core decompression with concentrated bone marrow cells is supported as a treatment option for her diagnosis.  All told, the requested left knee decompression including bone marrow aspiration and concentration and injection into lesion is likely to be superior over other treatment options.  Final Result: Three reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in orthopedic surgery 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.