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 for evaluation of the enrollees medical condition.Findings:  Two physician reviewers found that the medical studies have shown that the addition of three dimensional digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology and are 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: 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 the evaluation of the enrollees risk of breast cancer.Findings:  Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis.  Final Result: Three 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: All three physician reviewers are board certified in diagnostic radiology and are 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 30 hours per week of applied behavioral analysis (ABA) services for treatment of the enrollees autism spectrum disorder. Findings:  The physician reviewer found that the request for 30 hours per week of ABA services have been established as medically necessary for treatment of the patients autism. In this case, the patient presents with maladaptive behaviors that include elopement, disrobement, anger outbursts and self-stimulatory behavior and ABA services can be utilized to help induce brain plasticity, with the ultimate goal of retraining neural circuitry not compromised by the underlying pathogenetic processes that give rise to the developmental delays and social disconnection associated with autism. Therefore, ABA therapy at the frequency of the recommended 30 hours per week is medically necessary for treatment of the patients medical condition. 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 with special qualification in child 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested speech therapy for treatment of the enrollees speech delay. Findings: The physician reviewer found that the review of the submitted documentation and medical literature demonstrates the medical necessity of the requested therapy. Speech development is an important predictor for later problems, such issues with reading and spelling, among other learning difficulties. Law and colleagues examined the effectiveness of speech and language interventions for children with primary speech and language delay/disorder. The authors found that overall there is a positive effect of speech and language therapy interventions for children with expressive phonological and expressive vocabulary difficulties. In this case, the patient has significant expressive speech delay and language impairments. As such, speech therapy has been established as medically necessary in this clinical setting.Final Result: The reviewer determined that the requested therapy 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 pediatrics and neurology with special qualification in child 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 reimbursement and prospective authorization and coverage for the Eylea injections for treatment of the enrollees left eye non-ischemic central retinal vein occlusion.   Findings:  The physician reviewers found that based on current peer-reviewed medical literature, Eylea was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. In this case, there is an absence of macular edema. Clinical trials using Eylea demonstrate that the medication is effective at treating central retinal vein occlusion (CRVO) complicated by macular edema. This patients records demonstrate that the patient has not experienced macular edema as evidenced by the examination notes and optical coherence tomography (OCT) images of the macula. Final Result: All three reviewers determined that the medication at issue was not and is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in ophthalmology 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 cervical epidural steroid injection for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The records do not document that the patient has had adequate trials of conservative therapy.  The clinical notes do not provide details regarding recent physical therapy, trial of nonsteroidal anti-inflammatory drugs, or chiropractic therapy.  Additionally, the patient has poorly controlled diabetes, which an epidural steroid injection may worsen.  The progress note does not describe the patient as having radiculopathy. The current medical evidence supports conservative therapy as a first step in this clinical setting.  All told, the requested cervical epidural steroid injection 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for 24 weeks for treatment of the enrollees hepatitis C virus.  Findings: The physician reviewer found that according to 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 due to nonliver-related conditions. Patients with cirrhosis are high priority for therapy. The AASLD/IDSA guidelines cite data showing decreased survival with delay in therapy (Jezequel, et al). The ALLY-3 study demonstrated 71% cure rates in Sovaldi-experienced patients after 12 weeks of Sovaldi/Daklinza therapy (Nelson, et al). The AASLD/IDSA guidelines use this evidence to make a Class IIa, level C recommendation to treat Sovaldi-experienced patients with 24 weeks of Sovaldi, ribavirin and Daklinza.  Therefore, the requested medications are supported as 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 physician 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 Viekira Pak and ribavirin (24 weeks of treatment for treatment of the enrollees chronic hepatitis C virus genotype 1a. 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. The AASLD and IDSA guidelines do not support extension of therapy solely based on detectable viral load at four weeks into treatment. However, this patient does have early cirrhosis per recent ultrasound. Per the AASLD and IDSA guidelines, cirrhotic treatment-naive genotype 1a patients should be treated with Viekira Pak and ribavirin for 24 weeks. This recommendation is based on multiple high-quality clinical trials showing cure rates of over 90% and safety (Feld, et al; Poordad, et al; Ferenci, et al). For these reasons, the requested treatment with Viekira Pak and ribavirin for 24 weeks (an additional 12 weeks) is supported as 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 coverage for residential treatment center services for treatment of the enrollees behavior health condition.  Findings: The physician reviewers found that in this clinical setting, the services at issue were not and are not medically necessary for the treatment of the patient. There were no post-acute withdrawal symptoms. The patient was not a danger to himself or to others.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable. He was motivated and appeared to be working the program. No new problems had arisen and there was no evidence to indicate that returning him to his environment would lead to destabilization. The patient had just completed a residential treatment. Moreover, there was no indication that additional residential treatment would have provided significant improvement. The provided records demonstrated that he could have safely been treated at an ambulatory level of care in conjunction with a 12-step program and a sponsor. Residential treatment was not medically indicated as he did not require 24-hour supervision.  As such, the services at issue were not and are not medically necessary for the treatment of this patient.Final Result: The reviewers determined that the services at issue were not and are 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested L5-S1 transforaminal lumbar interbody fusion surgery for treatment of the enrollees medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity for the requested services. Fusion is recommended for patients with demonstrated spinal instability or the likelihood of iatrogenic instability. According to Resnick and colleagues Numerous studies have demonstrated the role of surgical decompression in this patient population; however, few have investigated the utility of fusion in patients without underlying instability. In addition, the evidence based medical guidelines do not support the use of discography as a stand-alone test to formulate treatment strategies for patients with low back pain (Eck, et al). In this case, the patient presents with chronic low back pain radiating into the lower extremities with bilateral foot numbness. Clinical exam findings documented sensory and motor deficits consistent with the L5 and S1 distribution, but there is no imaging evidence of disc herniation, central or foraminal stenosis at the L5-S1 level. Limited improvement was documented following left L5 and S1 selective nerve root blocks. A single-level discogram was reportedly positive at L5-S1, but outcomes have not been found to be consistently reliable for the low back based upon recent studies. This patients symptom generators have not been fully elucidated. There is no radiographic evidence of spondylolisthesis or spinal segmental instability on flexion and extension x-rays. In addition, a lumbar fusion adjacent to a two-level disc replacement would represent a hybrid-type complex surgical procedure for which there is a lack of significant long-term medical literature studies supporting its use. Therefore, the request for L5-S1 transforaminal lumbar interbody fusion surgery is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Synvisc-One injections (48 mg/6 ml syringe for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The evidence-based medical guidelines state that hyaluronic acid injections in the knee are recommended as a possible option for severe osteoarthritis for patients who have not responded adequately to recommended conservative treatments, to potentially delay total knee replacement.  There is insufficient evidence for other conditions, including patellofemoral arthritis, chondromalacia patella, patellofemoral syndrome, or osteochondritis dissecans.  This patient presents with right knee pain with reported difficulty weight-bearing and walking.  Right knee examination documented diffuse global tenderness with painful, but functional, range of motion.  She was status post right knee arthroscopic chondroplasty of the patellofemoral joint, removal of medial plica, and debridement of torn cartilage on the medial femoral condyle.  Updated radiographs showed minor degenerative osteoarthritis.  The current diagnosis is chondromalacia patella. There is a lack of compelling rationale to support the medical necessity of viscosupplementation in the setting of minor osteoarthritis/primarily patellofemoral osteoarthritis. Therefore, the requested Synvisc-One injections 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees risk for breast cancer.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, Skaane and colleagues found that the addition of three dimensional digital breast tomosynthesis to two dimensional full field digital mammography resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Thus, although additional studies are needed to confirm these findings, there is adequate data to support the utility of three dimensional digital breast tomosynthesis in this clinical setting. For these reasons, the breast tomosynthesis was likely to be more beneficial for evaluation of this patients medical condition than any available standard therapy.  Final Result: Two reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.   Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities.  This has been shown to be most useful in the evaluation of dense breasts.  In this patients case, her breasts have been described as heterogeneously dense.  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, especially considering the area of right-sided asymmetry.  Thus, digital breast tomosynthesis was likely to have been more efficacious than other treatment alternatives.Final Result: Three 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: All three physician reviewers are board certified in diagnostic radiology and are 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.