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: Two reviewers 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, 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 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 physician reviewers are 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 the LINX reflux management system for treatment of her medical condition.  Findings: Two physician reviewers found that the submitted documentation supports the requested services in this patients case.  The LINX reflux management system has been approved for lower esophageal sphincter augmentation.  Appropriate candidates for the procedure include those with inadequate symptom control with acid suppression therapy, including those patients with mild to moderate gastroesophageal reflux disease and a hiatal hernia less than 3 cm. This patient meets those specific criteria.  There is sufficient support for the requested services in this clinical setting.  Therefore, the requested LINX reflux management system is likely to be more efficacious than other treatment options.  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:  All three physician 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 breast tomosynthesis for evaluation of her medical condition.   Findings:  Two physician reviewers found that peer reviewed literature supports the use of tomosynthesis in this clinical setting. Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. For these reasons, tomosynthesis was likely to be more beneficial than any available standard modalities.   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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuous positive airway pressure (CPAP) rental for treatment of her medical condition.  Findings: The physician reviewer found that the current medical evidence does not support the equipment at issue in this clinical setting.  If a patient does not have hypertension, heart disease or a cerebrovascular accident, the criteria for the medical necessity for CPAP is an overall study AHI of 15 or greater.  In this patients case, her Epworth Sleepiness Scale score was below 15.  There is a lack of support for the equipment at issue in this patients case.  Therefore, CPAP rental was not and is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the equipment 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested FirstStep Plus genetic testing  for evaluation of the enrollees medical condition.  Findings: Three physician reviewers found that Chromosomal microarray (CMA) and Fragile X testing is recommended by the American College of Medical Genetics (ACMG) as a first-tier test for patients with autism spectrum disorder (ASD) (Schaefer and Mendelsohn). CMA has become the standard of care for diagnosis in patients with ASD. Increasing numbers of patients with ASD have been found to have underlying copy number variations. As such, it is possible that some copy number variations may also be associated with specific neuropsychological treatments or medications that have been shown to be more efficacious in patients with ASD due to that underlying cause. Additionally, copy number variations on CMA may inform about other complications and medical risks, some of which can be screened for and treated. All told, the requested testing is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested testing is 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:  Two reviewers are board certified in pediatrics and genetics and are actively practicing. One reviewer is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics. 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 a semi-electric hospital bed with a lift device (trapeze) and over bed table for treatment of her medical condition.  Findings: The physician reviewer found that the semi-electric hospital bed with a lift device (trapeze) and over bed table was not medically necessary for treatment of this patients medical condition status post knee surgery. The documentation does not indicate that the patient has a medical condition which required positioning of the body in positions not feasible with an ordinary bed. In addition, the patient did not require the head of the bed elevated for medical reasons such as problems with aspiration or congestive heart failure. Further, the documentation does not demonstrate that the patient required traction equipment, an immediate need for a change in body position, or frequent changes in body position. Moreover, there is a lack of evidence that this patient had a pressure ulcer that required specialized bedding. For these reasons, the documentation does not support the medical necessity of the semi-electric hospital bed with a lift device (trapeze) and over bed table.  Final Result: The reviewer determined that the equipment at issue was 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 with sub-specialty certification in neuromuscular 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 facial feminization surgery for treatment of her medical condition.  Findings: The physician reviewer found that with regard to whether the proposed procedure meets reconstructive surgery criteria, the patient presents with age-related changes of volume loss and loss of skin laxity of the face. There is a lack of evidence that the patients facial appearance is abnormal for a female. The requested procedure is not being performed to create a normal appearance as the patients facial features are normal for a female. In addition, the requested surgery does not offer more than a minimal improvement in the patients appearance as she would likely respond to facial rejuvenation and volumization, but not facial feminization surgery. Therefore, the requested surgery does not meet the reconstructive surgery criteria.  Final Result:  The reviewer determined that the requested surgery is not medically necessary or reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications:  The physician reviewer is board certified in plastic 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 an intravenous immunoglobulin (IVIG) infusion for treatment of her medical condition.  Findings:  The physician reviewer found that this patients records lack findings to support a diagnosis of chronic inflammatory demyelinating polyneuropathy  (CIDP).  Specifically, there are no significant clinical findings to support this diagnosis. The patients electromyography (EMG) was interpreted as normal and an EMG study alone is inadequate to evaluate for CIDP.  The standard work-up includes a spinal fluid analysis looking for elevated protein. Further, the records do not demonstrate a paraneoplastic etiology since the patient has no evidence of cancer as her lesions were biopsied and proven to be benign. The diagnosis of neuropathy was based on the finding of an abnormal anti-GD1a antibody which is a specific ganglioside that has been associated with an acute sensorimotor neuropathies in the Guillain Barre family. However, a study by Johannis and colleagues shows a poor predictive value using ganglioside testing for neuropathy as there are a high number of false positives. Further, Claudie and colleagues suggested that there is poor standardization among laboratories in testing for these antibodies. Overall, the patients positive anti-GD1a result is likely not clinically significant and there is a lack of evidence of an autoimmune neuropathy, paraneoplastic neuropathy, or CIDP.  Given these findings, the requested IVIG infusion is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in internal medicine and 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgical repair for treatment of his medical condition.  Findings: The physician reviewer found that diastasis recti is reserved for patients who have not had a previous midline celiotomy. It is common in smaller women after pregnancy where the midline between the rectus is stretched out. The bleeding from the stitch granulomas can be handled electively as an outpatient under local anesthesia. If it does progress to recurrent partial obstruction or significant enlargement, a case could be made for laparoscopic lysis of adhesions and large underlay ventral hernia repair. However, the records do not document an indication for the requested surgical repair of the ventral midline surgical scar diastasis. Thus, the requested surgery is not medically necessary for treatment of this 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.  Qualifications/Credentials: The physician reviewer is board certified in 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 inpatient rehabilitation services for treatment of her medical condition.  Findings: The physician reviewer found that the medical literature supports the medical necessity of the requested inpatient rehabilitation services for further treatment of this patients condition. Her provider has certified that she requires skilled nursing or rehabilitation services at least five days a week and the services require professionally trained personnel. Also, the patient needs to be able to participate for three hours a day in rehabilitation. The patient is making good progress at home and has been able to participate in three hours of rehabilitation a day. However, the records indicate that the patient has severe behavior problems secondary to hypoxic encephalopathy which is impeding her care. Further, her diabetes is not stable and she has some breakdown of skin . Additional breakdown of the skin could cause a severe wound which could lead to sepsis, and close blood glucose monitoring is indicated. Thus, the requested inpatient rehabilitation would give her the best chance to treat her behaviors by instituting a proper medicine regimen and providing intensive treatment by nursing and social services.  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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential mental health treatment for treatment of her behavioral health conditions.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Initially, this patient had a formidable psychiatric history characterized by behavioral dysregulation, impulsivity, mood symptoms and substance use that impacted multiple functional domains and jeopardized her developmental task of identity formation.  Subsequently, the patient began making positive strides in her recovery, family therapy and trauma processing.  The patient had a positive attitude in group.  She had a sponsor.  She was nervous about transition but focused in thought and appropriate in presentation.  She was committed to recovery and demonstrating good insight.  The patient was neither suicidal nor homicidal.  The patient was compliant with program rules, actively engaged in treatment, and appropriately interacting with peers. Her family was supportive and engaged in the recovery program.  Based on the documentation provided, the patient warranted ongoing comprehensive specialty care.  However, the illness burden no longer demanded placement in a 24-hour supervised setting. As such, discharge to a less restrictive setting would have been safe, appropriate and consistent with good medical practice in the United States.  Thus, residential mental health treatments were medically necessary initially, but not thereafter.Final Result: The reviewer determined that a portion of the services at issue was 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 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 breast tomosynthesis for evaluation of his medical condition.   Findings: Two physician reviewers found that the addition of digital breast tomosynthesis reduces false positives and increases cancer detection when compared to two dimensional full field digital mammography alone.  Three dimensional digital breast tomosynthesis allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue.  Given this support, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had the exam been done with two dimensional imaging alone.  Accordingly, breast tomosynthesis  was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.   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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested inpatient hospitalizations for infusions of intravenous immunoglobulin (IVIG) every two weeks for treatment of her common variable immunodeficiency.   Findings:  The physician reviewer found that a review of the documentations including vital sign flow sheet, treatment records and discharge summary do not support that the admission criteria have been met in this clinical setting. Overall, there are insufficient data to show hemodynamic instability, high fever or high risk infection, severe pain, systemic drug or toxin reaction, frequent inpatient monitoring, neurologic findings, acute renal failure, acute blood loss or emergency procedure occurred during hospitalization. Thus, the requested inpatient hospitalizations for infusions of intravenous immunoglobulin (IVIG) every two weeks are not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the services at issue are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in internal medicine with sub-specialty certification in allergy and immunology 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 chest surgery (repair of pectus carinatum) for treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation establishes the medical necessity for the surgery at issue. In this case, the patient presented with pectus excavatum, a congenital chest/breast deformity. This condition was treated with chest reconstruction using pre-pectoral implants. The patient has a well-recognized congenital deformity that requires complex reconstruction.  Reconstructive surgery is generally done to improve function but may also be done to approximate a more normal appearance, as in this case. Therefore, the chest surgery (repair of pectus carinatum) was medically necessary and is the standard of care for a congenital defect. All told, chest surgery (repair of pectus carinatum) was medically necessary and reconstructive in nature for treatment of the patients medical condition.   Final Result: The reviewer determined that the service at issue were medically necessary and reconstructive in nature for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  The reviewer is board certified in plastic 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.