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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested authorization and coverage for neuropsychological testing (Wechsler Preschool and Primary Scale of IntelligenceFourth Edition (WPPSI-IV), Vineland Adaptive Behavior Scales, Second Edition (VinelandII) and NEPSY-Second Edition). Findings:  The physician reviewer found that there is support for a portion of the requested services in this clinical setting. Specifically, the Wechsler Preschool and Primary Scale of IntelligenceFourth Edition (WPPSI-IV) and Vineland Adaptive Behavior Scales, Second Edition (VinelandII) are medically appropriate in this clinical setting.  Both these assessment tools would provide more information as to the patients cognitive skills, ultimate prognosis, social skills and motor-adaptive problem solving skills. However, there is a lack of evidence-based literature and research to support NEPSY-Second Edition as a neuropsychological assessment tool for the evaluation of this patient. There is some literature to support its use for children with very complex brain injury or those children diagnosed with cancer and in those limited cases, it was performed with children older than three years of age.  The American Academy of Pediatrics (AAP) identify three major diagnostic challenges in the comprehensive assessment of a child with a suspected ASD: determining the childs overall level of functioning; making the categorical diagnosis of an ASD; and determining the extent of the search for an associated etiology. Per the AAP guidelines, the important part of the comprehensive evaluation for this patients case is the developmental and/or psychometric evaluation.  In this patients case, a DAYC has been performed by the school but this evaluation is only a screening test. It is not a psychometric evaluation. So, in this patients case a psychometric evaluation is medically indicated. Final Result: The reviewer determined that a portion of the requested services is medically necessary for the evaluation of the patients medical condition. Therefore, the Health Plans denial should be partially overturned. Credentials/Qualifications: The reviewer is board certified in pediatrics 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 enrollee's risk for breast cancer. Findings: Two physician reviewers found that there are sufficient supports for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in detection of small cancers compared to two-dimensional imaging alone. Although the patient was asymptomatic, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.   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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for eight weeks for treatment of the enrollees hepatitis C virus. 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 should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight 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: 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: Three physician reviewers found that 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, by separating the various layers of breast tissue, one can better detect abnormalities. This particular patient has breasts that have been described as being heterogeneously dense. While one could make the argument that her mammogram has not changed since the last study, it is specifically this subset of patients with dense breast tissue that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, in this clinical setting, the use of the digital 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 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 enrollee risk for breast cancer.  Findings: Two physician reviewers found that there is sufficient support for the service at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms. This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and biopsies and increase in detection of small cancers compared to two-dimensional imaging alone. Although asymptomatic, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment for the enrollees behavioral health condition. Findings: The physician reviewer found that in this clinical setting, the services at issue were not medically necessary for the treatment of this patient. The patient was admitted with a Clinical Institute Withdrawal Assessment (CIWA) of 19. His vital signs were normal. The records also reflect that the patients maintenance dose of Ativan was within the range of what is used clinically for some anxiety disorders.  On admission, he was not suicidal or homicidal. He was medically stable.  Despite his self-ratings of 10/10 for most of his symptomatic features, it should be noted that the complications of his treatment were iatrogenic in nature. The patient was placed on a complicated medication regimen relative to a benzodiazepine withdrawal.  This same process could have been conducted on a daily outpatient basis with a compliant patient who was well informed, such as this patient. The records do not indicate that this patient received treatment at a lower level of care. There was no clinical evidence to indicate that this patient had biomedical complications, insight or learning deficits, or an unstable recovery environment that required 24 hour nursing or medical supervision.  Moreover, his course of treatment was not complicated by overwhelming or untreated psychiatric conditions. As such, he did not require 24 hour nursing and medical supervision at residential level of care. Therefore, the residential treatment center services were not medically necessary for treatment of this patient.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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc bilateral knee injections for treatment of the enrollees bilateral knee degenerative joint disease.  Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee.  Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis were efficacious during a 54-month follow-up period.  Evidence-based, peer-reviewed literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee.  Viscosupplementation has been found to be safe and effective and allow for delay of total knee replacement.  In this case, the patient has been diagnosed with osteoarthritis of both knees.  The patient has undergone prior arthroscopic surgeries bilaterally. She has undergone two prior series of Orthovisc injections which resulted in long-term pain reduction.  The patient has worsening bilateral knee pain and functional impairment that has failed to respond adequately to other conservative treatment.  All told, the requested Orthovisc bilateral knee injections are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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 a referral to a Naturopathic physician for treatment of the enrollees menopause.  Findings:  The physician reviewer found that the review of the submitted documentation and relevant literature fails to demonstrate the medical necessity of the requested referral. There are many options for treatment of menopausal symptoms which include hormonal and non-hormonal therapies. Treatment of menopausal hot flashes, range from symptomatic treatments, over-the-counter supplements, selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs),  gabapentin, clonidine, and various hormonal treatments (Santen, et al). The patient expresses a desire for a compounded bioequivalent hormone therapy. There is a lack of evidence that compounded hormone therapy, which is not U.S. Food and Drug Administration (FDA) approved, is any more effective or safer than FDA-approved options. However, a number of expert groups, including the North American Menopause Society, American College of Obstetricians and Gynecologists, and Endocrine Society, all of whom advise against the use of custom-compounded hormones (Martin and Barbieri). Overall, there is a lack of data in the peer-reviewed literature that supports treatment by a Naturopathic physician in this clinical setting. Accordingly, the request for a referral to a Naturopathic physician has not been established as medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested referral 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 obstetrics and gynecology 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 Prometheus Anser IFX (measurement of serum infliximab and the antibodies to infliximab) for evaluation of the enrollees ulcerative colitis.  Findings: Three physician reviewers found that the superior efficacy of the services at issue has not been demonstrated.  The Anser IFX test was ordered to determine the cause for possible loss of response to Remicade.  The use of Anser IFX testing to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in high-quality controlled clinical trials.  The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold drug levels been established.  Studies have found that anti-infliximab antibodies can be transient, and disappear over time, with many patients who have these antibodies maintaining their response.  Although loss of response to infliximab is common, there was a lack of standard guidelines defining a therapeutic strategy at the time of testing.  A systematic review by Yarur and colleagues noted that future prospective controlled studies are needed, especially considering anti-tumor necrosis factor levels are influenced by several variables that can fluctuate over time and among individuals.  Thus, Prometheus Anser IFX testing was not likely to have been of greater benefit than other methods of evaluating this patient.Final Result: Three reviewers determined that the services at issue were 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 physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Valtrex for treatment of the enrollees viral infection. Findings: The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  The patient reported chronic fatigue.  The laboratory studies were significant for an elevated Epstein-Barr virus and a borderline high cytomegalovirus level.  The plan of care was to treat for a viral infection with valacyclovir.  Per the patient, generic valacyclovir is made in a factory that contains gluten products while Valtrex is made in a gluten free factory.  The documentation provided does not describe gluten intolerance or any significant food allergies.  There is no documentation that the patient is allergic to gluten or has a diagnosis of celiac disease.  When a generic drug product is approved by the U.S. Food and Drug Administration (FDA), it has met rigorous standards established by the FDA with respect to identity, strength, quality, purity and potency.  Generic drugs are required to have the same active ingredient, strength, dosage form and route of administration as the brand name product.  In this case, there is insufficient documentation indicating that the patient has had a significant adverse reaction to the generic drug, valacyclovir.  Furthermore, the mainstay of treatment for patients with infectious mononucleosis and other manifestations of primary Epstein-Barr virus disease is supportive care.  Acetaminophen or nonsteroidal anti-inflammatory drugs are recommended for the treatment of fever, throat discomfort, and malaise.  All told, Valtrex is not medically indicated for the treatment of this patient.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 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 tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category in 2014 due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to this patient than had her exam been done with two-dimensional imaging alone. Accordingly, the breast tomosynthesis that was 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 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 the enrollees breast cancer screening.  Findings: Three physician reviewers found that the study noted the breast composition as extremely dense. There were no suspicious micro calcifications, architectural distortion or dominant mass noted in the study. The Health Plan has denied the request for reimbursement for the digital breast tomosynthesis. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. There is clinical support for the service at issue. According to 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 noted that integrated two dimensional and three dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  In sum, digital breast tomosynthesis was likely to have been more effective than other methods of evaluating this patient.Final Result: Three reviewers determined 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.