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. Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The American College of Radiology has urged tomosynthesis be removed from the investigational category due to the significant advantages it brings particularly in patients with heterogeneously and extremely dense tissue as in this patient under review. The technique often allows the provider to separate dense glandular breast elements from underlying mass/architectural distortion 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) protocol was likely of more benefit to this patient than had the study been done with 2D imaging only. 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: 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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Tomosynthesis allows the provider to separate various layers of breast tissue to better detect abnormalities. This has been shown to be most useful in the evaluation of the dense breast tissue. 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. As such,  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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee requested continued residential treatment for treatment of her medical condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  The patient had long struggled with mood symptoms and had profound eating disordered behaviors.  She had physical sequelae from her eating disorder, and both psychiatric and medical comorbidity.  Per the medical records, discharge at this time would have been premature and more than likely would have resulted in undue morbidity and prompt readmission.  The patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  The duration of services for a case of this complexity was consistent with community standards.  Finally, the entire course of care was reasonably expected to improve her condition and prevent a more serious episode of illness.  All told, continued residential treatment 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 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 Orthovisc injection for treatment of her medical condition.   Findings:  Two physician reviewers found that the submitted documentation fails to demonstrate the superior efficacy of the requested services.  There have been carefully conducted double-blinded studies which do not document any clinical effect from hyaluronan injection.  This patient has had multiple injections, and with each injection and each exposure to the antigen, there is an increased risk of allergic response. There is also risk of iatrogenic infection being introduced into the joint during the process of injection.  Researchers performed a meta-analysis of the efficacy of viscosupplementation.  The authors noted that in patients with knee osteoarthritis, viscosupplementation is associated with a small and clinically irrelevant benefit and that there is an increased risk of serious adverse effects.  All told, the requested Orthovisc injection is not likely to be of greater benefit than other treatment options.   Final Result: Two reviewers determined that 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 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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a 24-week course of Sovaldi, Daklinza and ribavirin for treatment of his hepatitis C virus.  Findings:  The physician reviewer found that according to medical guidelines, 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 liver transplant are highest priority for treatment. In genotype 3 patients who have had a liver transplant, therapy is recommended with Sovaldi, Daklinza, and ribavirin for 12 weeks. This is based on the ALLY-1 study, which showed a high cure rate in liver transplant patients. Additionally, because the patient has failed Sovaldi and ribavirin for 24 weeks, the guidelines recommend 24 weeks of Daklinza, Sovaldi, and ribavirin in this case. This is based on the ALLY-3 study, which demonstrated poor cure rates (only 71% in Sovaldi-experienced patients) after 12 weeks of therapy. The guidelines cite study data reporting that delay in treatment may result in decreased survival. For these reasons, the requested treatment with Daklinza, Sovaldi, and ribavirin for 24 weeks is medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer 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: 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Pradaxa for treatment of her medical conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the medication at issue.  Pradaxa is used for the treatment of deep venous thrombosis and pulmonary embolism in patients who have been treated with a parenteral anticoagulant for five to ten days; and to reduce the risk of recurrence of deep vein thrombosis and pulmonary embolism in patients who have been previously treated.  The Health Plan requires that Xarelto should be tried first and if the patient is unable to tolerate it then Pradaxa may be tried, and this requirement is medically appropriate.  In this case, the patient was treated with Pradaxa for a pulmonary embolism.  The patient did not receive any parental anticoagulant before initiating treatment with Pradaxa.  Furthermore, the patient had not tried and failed treatment with Xarelto.  All told, Pradaxa was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that the medication at issue was not and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient sub-acute level two care services for treatment of his medical condition. Findings: The physician reviewer found that the documentation submitted for review fails to establish the services at issue as medically necessary in this clinical setting. The patient has made very slow progress in skilled therapies. He has multiple comorbidities and based on the documentation submitted for review, it does not appear that he will reach his baseline or show further improvement in a predictable period with continued skilled therapies. The patient requires custodial care, and continued skilled therapies are not indicated.  Therefore, continued skilled nursing facility treatment services were not and are not medically necessary for treatment of the patients medical condition.  Final Result:  The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The physician reviewer is board certified in physical medicine and rehabilitation 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 surgical repair of the right bicep and shoulder for treatment of his medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  With regard to the treatment of ruptures of the long head of biceps tendon, the guidelines indicate that it can almost always be managed conservatively because there is no accompanying functional disability.  With regard to the evidence of impingement, the guidelines necessitate conservative treatment with an exercise rehabilitation program and corticosteroid injections and documentation of trial/failure before surgical considerations for subacromial decompression.  As such, the request for biceps tendon repair is not medically necessary.  Given the lack of documentation indicating an exercise rehabilitation program and corticosteroid injections, request for arthroscopic surgery is also not indicated.  All told, the requested surgical repair of the right bicep and shoulder 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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested dialectical behavior therapy intensive outpatient program services for treatment of his behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients fragmented ego, symptom burden, limited coping skills and self-defeating coping strategies increase the risk for relapse and a poor clinical outcome in the absence of appropriate treatment.  There is sufficient support for the services at issue in this clinical setting.  The specific therapy is an evidence-based treatment that benefits those with character pathology and addictive illness.  The setting allows for closer observation of symptom evolution during the delicate negotiation of pharmacologic management for this patient being treated with multiple psychopharmaceuticals.  There is an inherent complexity in this case as obsessive-compulsive disorder typically needs high-dose serotonergic enhancement while antidepressant medication can exacerbate bipolar illness, particularly the rapid cycling variant of the disorder.  Finally, the duration and frequency of programming afforded by the level of care enables re-visitation of identity formation, a developmental task that has been compromised for this patient, in addition to further consolidation of relapse prevention strategies.  The record reflects that the patient has been engaged in active treatment.  Both the setting and primary therapeutic modality are safe, appropriate and consistent with good medical practice.  All told, dialectical behavior therapy intensive outpatient program services were and are medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were and 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 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 gene testing for evaluation of her medical condition. Findings:  Two physician reviewers found that there is sufficient support for the requested services in this clinical setting.  In about one-third to one-half of cases, a paraganglioma is a component of an inherited syndrome. Based on available data, genetic screening is advised for all patients diagnosed with a paraganglioma.  Diagnosing a genetic syndrome is important for deciding on further management to prevent malignancies.  All told, the requested gene testing is likely to be of greater benefit than other methods of evaluating this patient.  Final Result: Two reviewers determined that the requested services are 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 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 Xeljanz for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The extent of this patients disease is severe and has been unresponsive to prior therapies.  She has tried and failed treatment with oral steroids, intralesional steroids and dinitrochlorobenzene.  Xeljanz has been the only treatment which has shown benefit in treating alopecia universalis.  The request for coverage of Xeljanz should be approved as there are no alternative treatment options which would be considered to be as effective at this time.  All told, Xeljanz 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 dermatology 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 cervical spine magnetic resonance imaging (MRI) and lumbar spine MRI for the evaluation of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  There is considerable controversy concerning when to order imaging studies to evaluate low back pain.  Per the medical evidence, generally MRI is not warranted in the acute setting. In the setting of low back pain in which the patient is a candidate for surgery or other intervention, then MRI is an appropriate modality.  In general, plain x-rays are often of very limited value. They serve to evaluate the patient for significant structural abnormalities such as fractures, malalignments or congenital anomalies.  However, MRI is not as beneficial for evaluating patients for a cause for radiculopathy.  In this case, the Health Plans denial is appropriate.  There is support for an MRI  in anticipation of some sort of intervention.  Prior to an intervention, it is not unreasonable to attempt a trial of conservative treatment such as physical therapy, a targeted exercise program, or methodical use of anti-inflammatory drugs.  In this patients case, there are no signs or symptoms that would warrant immediate invasive therapy.  Surgery or other interventions should be the last resort, not the first option, for symptoms that have been present for a highly significant amount of time.  All told, the requested cervical spine MRI and lumbar spine MRI are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the compounded medication, guaifenesin/pseudoephedrine HCL, for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the requested compounded medication is not medically necessary for treatment of the patients medical condition. The patient is chronically taking the compound guaifenesin/pseudoephedrine. The U.S. Food and Drug administration (FDA) approved package insert recommends the use of this medication for a maximum of seven days for an acute problem, not chronically as taken by this patient.  The pseudoephedrine part is a sympathomimetic that is chronically stimulating her heart. It is a stimulant, and is currently banned from many sports competitions in various countries. The patient reports tachycardia which is an effect of chronic sympathetic stimulation. There is a lack of indication for treatment of this compounded medication. In sum, the requested compounded medication chronically is not consistent with the FDA approved indications and not medically necessary for treatment of the patients medical condition.  Final Result: The reviewer determined that the requested compounded 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 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.