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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested deep tissue massage physical therapy for treatment of his medical condition.  Findings:  The physician reviewer found that deep tissue massage physical therapy is medically necessary for treatment of the patients medical condition. According to the documentation submitted for review, the patient does not have, through anatomical studies, documentation of a specific anatomical cause for radiculopathy such as recurrent or new herniation in the pattern that would likely produce pain radiating into the dorsum of the foot or complications of instrumentation effecting nerve roots. He likely has adjacent segment changes above the levels of fusion. He will require ongoing attention to deep spinal muscles, the multifidus and erector spinae muscles in order to minimize the risk of progressive adjacent segment disorder over time. It is reasonable that his physical therapy include all of the standard techniques of physical therapies, modality therapies, exercise therapies and massage therapies to be utilized through a skilled physical therapist. This approach will likely maintain core body strength and minimize the possibilities of progression. A medical study endorses the integration of massage therapy as a core healthcare service. In this case, the patient will likely benefit from massage therapies including deep tissue massage for treatment of his low back and leg symptoms.   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 orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested gene testing (CancerType ID) for evaluation of her medical condition.  Findings:  Two physician reviewers found that the gene testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Although the breast cancer index is a promising genomic test to help determine which patients would benefit from extended endocrine therapy, to date there is a lack of prospective data to support its use. Currently, ongoing trials are being conducted with results not yet published to determine its utility. Moreover, both the National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) do not endorse use of CancerType ID testing for duration of endocrine therapy.  Final Result: Two reviewers determined that the testing at issue was 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:  One reviewer is board certified in internal medicine with sub-specialty certification in hematology and oncology and is actively practicing. Two reviewers are board certified in internal medicine with sub-specialty certification in oncology 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 septoplasty and submucous resection inferior turbinate for treatment of his medical condition.  Findings:  The physician reviewer found that septoplasty and submucous resection inferior turbinate are medically necessary for treatment of the patients medical condition. The medical literature reports that nasal airflow was measured before and after septoplasty due to nasal obstruction because of septal deviation. The medical literature included 536 participants and all participants showed objective evidence that septal surgery improves nasal patency. Moreover, a medical study conducted a prospective observational outcomes multicenter study to assess disease-specific quality of life outcomes after nasal septoplasty in adults with nasal obstruction. The authors concluded that in patients with septal deformity, nasal septoplasty results in significant improvement in disease-specific quality of life, high patient satisfaction, and decreased medication use. According to the documentation submitted for review, the patient presents with persistent and symptomatic nasal airway obstruction which has remained refractory to medical management. The patient has been properly managed with a trial of topical medications and allergy immunotherapy. The patient did have some improvement of symptoms of nasal blockage with the use of one topical medication, but due to the risks of development of rhinitis medicamentosa, that medication was discontinued. Although this patients symptoms improved with the use of a topical medication, the use of topical vasoconstrictor medications that contain preservatives have a deleterious effect on the nasal mucosa. Most providers utilize this technique to determine whether the patient may benefit from surgical procedures, and remind patients to use the medication only for a trial period. In this case, the patient has physical evidence of both deviation of the septum and inferior turbinate hypertrophy which failed medical therapy. As such, the requested services are medically necessary for treatment of the patients nasal obstruction.  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 otolaryngology 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 transcatheter MitraClip repair for treatment of his medical condition.  Findings:  Two physician reviewers found that the transcatheter MitraClip repair performed was not likely to be more beneficial for treatment of the patients medical condition than available standard modalities. The medical literature does not support a definitive opinion or evidence based data supporting sustained benefit and improved long term outcomes associated with this procedure at this time. Two authors performed a literature review to evaluate whether there are any indication criteria, process, and structural requirements, or scientific society and institutional guidelines for the use of the MitraClip System. The authors concluded that The MitraClip System is a promising procedure, but evidence-based indication criteria, structural, and process requirements for its use are lacking. Further results from prospective, randomized controlled trials are needed to determine patients, potential adverse events, device durability, and long-term follow-up. Based on the lack of support in the literature, the services at issue were 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 services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in cardiovascular disease 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 HCPCS code J9310, rituximab injection and CPT code 96365, intravenous infusion for therapy, prophylaxis, or diagnosis, initial up to one hour, and 96366, intravenous infusion for therapy, prophylaxis, or diagnosis, each additional hour for treatment of her medical condition.  Findings:  The physician reviewer found that this patient presented with multiple sclerosis, with ring enhancing lesions. She reportedly stabilized with Rituxan previously.  The records do not indicate trials of any other multiple sclerosis disease modifying agents. These are well-studied and U.S. Food and Drug Administration (FDA) indicated medications for the management of multiple sclerosis.  The trial data for use of Rituxan for multiple sclerosis is not of similar scientific quality.  All told, the requested services are 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 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 the SmartPill Wireless Capsule Motility procedure for evaluation of her medical condition.  Findings:  Two physician reviewers found that there is a lack of support for the requested services in this clinical setting.  The SmartPill provides temperature data throughout the gastrointestinal tract.  Additionally, it provides pH data, but this is only used to estimate gastric emptying time and identify arrival in the cecum.  This patient already has a diagnosis of gastroparesis.  The information the SmartPill will provide is of limited value in this patients case, and the results are unlikely to influence management.  All told, the requested SmartPill Wireless Capsule Motility procedure is not likely to be superior over other methods of evaluating this patient.   Final Result: Two reviewers determined that the requested services are 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 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 weekly electro-acupuncture for treatment of his medical condition.  Findings:  The physician reviewer found that according to the documentation submitted for review, the patient has been treated with multiple acupuncture sessions.  The acupuncture provider documented that after his last acupuncture series, the patient has improved activities of daily living, range of motion and reduction of pain levels. The acupuncture provider recommended an additional specific number of visits. Thus, further acupuncture treatment is medically necessary in this clinical setting to address the patients medical condition. However, as the provider has recommended a specific number of additional sessions for further functional improvement, such treatment plan is reasonable and medically necessary to help the patient transition to self-care. Moreover, open-ended treatment on a weekly basis is seen as maintenance in nature and not supported as medically necessary. Given the clinical documentation submitted for review, a portion of the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that a portion of the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: The reviewer is board certified in oriental 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 a 12 week course of Harvoni for treatment of his hepatitis C virus (HCV).  Findings:  The physician reviewer found that in managing patients with chronic hepatitis C virus, denying treatment for a chronic disease such as HCV, because the patient does not have an advanced stage disease is not supported by the peer-reviewed literature. The position of American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) on hepatitis C virus does not stratify patient as early or late. The recommendation is not to deny patients treatment if they have early stage disease, but to provide treatment to avoid untoward complications from advanced disease, including liver failure and extrahepatic complications from hepatitis C virus. Moreover, a report of long-term follow-up of 820 patients with biopsy-confirmed stage F0 or F1, a 15% rapid progression of fibrosis was noted, as compared to those who were treated earlier where the long-term survival was better. For the reasons provided above, the request for a 12 week course of Harvoni is medically necessary for treatment of the patients hepatitis C virus genotype 1. Final Result: The reviewer determined that the 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested an in office sleep study for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  She does not have obstructive sleep apnea, central sleep apnea or mixed sleep apnea.  A repeat polysomnogram in the office is not indicated.  The current medical evidence does not support the requested services in this clinical setting.  All told, the requested in office sleep study is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation 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 pulmonary disease 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 Avastin for treatment of his medical condition.  Findings:  Three physician reviewers found that the current medical evidence does not support the services at issue in this clinical setting.  Avastin is not U.S. Food and Drug Administration (FDA) approved for thymoma and is not found to have a non-FDA approved indication in major drug compendia.  The medical literature does not support Avastin for the treatment of this patient.  All told, the superior efficacy of Avastin has not been established. Final Result:  Three reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. 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.  All told, the requested treatment with Harvoni for 12 weeks is medically necessary for the treatment of this patients hepatitis C infection. 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested partial hospitalization program level of care services and intensive outpatient services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that modern psychiatric practice aims to place patients in the least restrictive treatment setting.  In general and if feasible, community intervention settings offer optimization of treatment gains.  However, transient placement in more restrictive settings is often clinically appropriate.  In this case, the patient was extraordinarily ill upon presentation.  In the absence of an intensive course of treatment, a poor outcome was expected.  Additionally, from the community standard perspective, it is common to utilize partial hospital and intensive outpatient programs in step-wise fashion upon discharge from acute hospitalizations, and treatment stays under these circumstances most often exceed 72-hours.  Based on the physician and therapy notes, this patient was engaged in active treatment but had not consolidated the therapeutic treatment gains necessary to succeed in a less restrictive setting.  The disputed services were at least in part for purposes of diagnostic assessment and shaping of future clinical interventions.  The patient did not possess the clinical stability or harmonized support network to succeed in the outpatient setting.  The services in dispute were reasonably expected to improve her condition and prevent a more serious episode of illness.  Thus, partial hospitalization program level of care services and intensive outpatient services from were 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 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 nerve damage graft product (Neuromend) for treatment of his medical condition.   Findings:  Two physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  Based on the operative note, a conduit was used as a wrap around a primary repair.  As noted in the medical literature, there is limited scientific (animal and clinical) evidence (in the peer reviewed literature) regarding its efficacy. The material is expected to fully resorb between 4 and 8 months post implantation.  Per the medical evidence, the services at issue were not likely to have been more beneficial than other treatment options. Final Result: Two reviewers determined that the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in plastic surgery with sub-specialty certification in hand surgery and is actively practicing.  Two reviewers are board certified in 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.