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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the automated whole breast ultrasonography for evaluation of the enrollees left breast carcinoma status post lumpectomy. Findings:  The physician reviewer found that the records provided for review document that this patient has declined to have conventional mammography to avoid excessive exposure to radiation since 2011 and has been evaluated with annual automated whole breast ultrasonography exams. The American College of Radiology (ACR) does not recommend automated whole breast ultrasonography as a screening tool for breast cancer detection. The use of this technique has proven to be of some benefit in patients with dense tissue for use as an adjunct to conventional mammography. Final Result: The reviewer determined that the diagnostic procedure at issue was not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The physician 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for MLH1, MSH2, MSH6, and PMS2 full sequence and duplication/deletion variants gene analysis (CPT codes 81292, 81294, 81295, 81297, 81298, 81300, 81317, and 81319) for evaluation of the enrollees risk for cancer. Findings:  Two physician reviewers found that a patient should be tested for hereditary colon cancer Lynch syndrome if a personal or family history indicates that the patient may be at an increased risk for Lynch syndrome, genetic test results provide the most accurate way to assess that patients cancer risk. Genetic testing for hereditary colon cancer Lynch syndrome should be considered if the patient has a history of colorectal or endometrial cancer before age 50, colorectal cancer with MSI-high histology before age 60, mucinous, Signet ring, tumor infiltrating lymphocytes, Crohns-like lymphocytic reaction histology, or medullary growth pattern. Testing is also indicated for patients with a family history of two or more relatives with a Lynch syndrome cancer with one before the age of 50, three or more relatives with a Lynch syndrome cancer at any age, or has a previously identified Lynch syndrome mutation in the family. None of these conditions apply to this patients personal family history. Final Result: Two reviewers determined that the requested testing is 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 medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the genotype testing for evaluation of the enrollees bipolar disorder. Findings:  Three physician reviewers found that in the peer-reviewed medical literature  noted that, in some circumstances in clinical practice, phenotyping of cytochrome P450 enzymes may be relevant. However, sufficient high-quality, replicated, and controlled studies demonstrating that pharmacogenetics and pharmacogenomics reliably improve health outcomes are not yet available. In addition, a study reported that genetic testing may not be reporting relevant clinical information and that no head-to-head comparisons have not been done proving that genetic studies are of clinical benefit. Overall, there is a lack of evidence to show improved health outcomes due to genetic testing. Final Result: All three reviewers determined that the testing at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in psychiatry 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 digital breast tomosynthesis for the enrollees breast cancer screeningFindings:  Three physician reviewers found that the patient was asymptomatic with respect to her breasts.  On 6/6/16, she underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. Her breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis performed on 6/6/16. Per the Health Plan, the service at issue was investigational for the evaluation of this patient. 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 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 particular patient, she 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 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.  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: Upheld Decision of Health Plan

An enrollee has requested authorization and coverage for medication, promethazine DM cough syrup. Findings:  The physician reviewer found that the medical literature shows that the use of promethazine DM has the potential to cause increased anticholinergic side effects, such as sedation. The use of this medication can also enhance the adverse/toxic effect of other anticholinergic agents. Therefore, it should be used with caution in patients with an elevated blood pressure. This patient was seen in urgent care for symptoms of cough, sore throat and sinus pressure.  The use of analgesics and antipyretics, saline irrigation, and intranasal glucocorticoids is recommended for symptomatic management of patients with acute sinusitis. As such, in this patients case, the documentation does not show a medical indication to use this drug for treatment of acute sinusitis.  Therefore, the requested promethazine DM is not medically necessary 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

An enrollee has requested reimbursement for digital breast tomosynthesis that was performed. Findings:  The physician reviewer found that the patient had a digital breast tomosynthesis performed as part of her routine screening mammography. At issue is whether digital breast tomosynthesis is superior to two dimensional digital mammography in the detection of breast cancer in a routine screening population. The medical studies have shown that the addition of three dimensional digital breast tomosynthesis reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional digital breast tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. All told, there is sufficient evidence supporting the use of digital breast tomosynthesis for this patients routine breast cancer screening. Final Result: The 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: the 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 digital breast tomosynthesis for evaluation of the enrollee, who presented for a breast screening mammogram. Findings:  Two physician reviewers found that the report noted a positive family history of breast cancer and calculated lifetime risk of the disease of 20.9%. The study revealed no evidence of malignancy.  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 an increase in detection of small cancers when compared to two dimensional imaging alone. Breast tomosynthesis provides advantages to radiologists interpreting mammograms. Therefore, the addition of digital breast tomosynthesis on 8/3/16 to the usual two dimensional protocol was likely to be more effective to the patient than had her examination been performed using 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 breast augmentation for treatment of the enrollees gender dysphoria. The surgical concept of treating breasts from male-to-female transgender is well-established and documented within the medical literature. According to Weigert and colleagues, Breast augmentation in male-to-female transsexuals is part of gender reassignment surgery. Hormonal feminization might not be sufficient to induce mammogenesis, so many patients seek surgery for their chests to resemble the female gender. However, the medical necessity of breast augmentation for transgender females with gender dysphoria is a case specific determination. In this patients case, based on the overall level of documentation and review of the submitted photographs, the patient has evidence of female breast development. Photographs depict breast development that is consistent with a relatively normal adult female appearance for a female, although on the smaller side. There is a well-developed inframammary fold and projected breasts. Augmentation mammoplasty, in this patient, would be to enhance the volume and appearance of a relatively normal structure. Therefore, this procedure would be consistent with cosmetic surgery. This patient has been treated with hormone therapy and the submitted photographs document the presence of visible breast tissue. As such, the patient does not present with an abnormal structure of the body.Findings:The physician reviewer found that the requested procedure is not medically necessary for treatment of the patients medical condition and is not reconstructive in nature. Therefore, the Health Plans denial should be upheld.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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a positron emission tomography (PET) scan performed for evaluation of the enrollees chest pain. Findings:  The physician reviewer found that although solid or ground glass nodules are of greater concern for malignancy than round solid nodules, the use of PET imaging in a nodule under 8-10 mm in diameter is not indicated as the resolution capability of the technique in such a small nodule is limited. As recommended for surveillance of pulmonary nodules, PET should be considered if the incidental nodule exceeds 10 mm in diameter. Based upon these published guidelines, the PET scan performed was not medically necessary for evaluation of this patients semi solid nodule measuring 4 x 5 mm. Final Result: The reviewer determined that the requested diagnostic procedure is 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for digital breast tomosynthesis performed. Findings:  The physician reviewer found that there were no prior mammograms available for comparison.  There were no masses, however, there was an area of clustered indeterminate calcifications in the anterior third of her left breast.  Applying the same basic concept as computed tomography 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 particular patient, this mammogram demonstrated what were felt to be suspicious clustered calcifications.  Tomography has been shown to be of value in better delineating and characterizing calcifications. One aspect of tomosynthesis is that it can better determine that the calcifications are, in fact, clustered, and not simply superimposed.  It is still not unreasonable, as this was a screening study, for the patient to return for specific spot compression and possibly magnification views.  In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The 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: the 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 reimbursement for residential mental health and substance use disorder treatment for treatment of 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 patients post-acute withdrawal symptoms were not severe in nature.  He was not a danger to himself or others, nor was he aggressive or violent.   He was cognitively intact and he was not gravely disabled.  There were no emotional, behavioral, cognitive, or impulsive symptoms that would warrant this level of care. He was medically and psychiatrically stable to the extent that he did not need a 24-hour, 7 day a week facility to render the remainder of his care.  His medication management and anti-craving medications could have been performed in an ambulatory setting.  He had a sponsor.  There was no evidence of a high degree of impulsivity, agitation, depression, mania, hallucinations, or any other significant symptom that would interfere with his care.  He was motivated and appeared to be working the program.  He was cooperative and participating in his treatment plan.  This was his first substance abuse treatment, and although he continued to struggle with his emotions and required further treatment to help develop coping skills, this did not require the structured environment of a residential setting. The patient could have been stepped down to an ambulatory level of care, such as partial hospitalization or intensive outpatient level of care.  The patient no longer met the American Society of Addiction Medicine clinical guidelines for residential level of care. Therefore, the residential mental health and substance use disorder treatment from 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 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 reimbursement for residential treatment center (RTC) eating disorder services for treatment of the enrollees eating disorder. Findings:  The physician reviewer found that the residential treatment eating disorder services were medically necessary for treatment of the patients medical condition. There is no single diagnosis in and of itself that meets typical criteria for residential placement in this case. However, the confluence of her medical conditions and distorted schemas, and their concerning totality of sequelae and subsequent functional impairment, warranted aggressive treatment in a supervised setting. Further, the quick re-admission to the residential level of care represented a significant variable in support of a conservative hospitalization. In the days leading up to discharge, the patient was described as anxious, disconnected and disengaged. She required medication for her anxiety. She felt that she was overweight. She was angry that she was gaining weight. She engaged in eating disordered behaviors at meal time. Her blood sugars were inconsistent, ranging from 61 to 324. She needed nursing assistance with insulin administration and her insulin pump was not working properly. Moreover, her treating providers recommended continued residential treatment. Longitudinally, the patient had struggled with eating disordered-behaviors in context of diabetes since adolescence, and she had previously failed treatment in less restrictive settings. Based on the entirety of data, safe and effective treatment could not have been reasonably provided in a less restrictive setting. The residential placement was reasonably expected to improve the patients condition and prevent a more serious episode of illness. In sum, the services at issue were medically necessary for treatment of the patients behavioral health condition.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.