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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Otezla therapy for the treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested medication in this clinical setting.  This patient has tried and failed therapy with multiple topical steroids and a topical Vitamin D analogues.  However, he has not been treated with other first-line agents and there are no documented contraindications to any of these therapies.  The Health Plans requirement of a trial and failure of two preferred formulary medications is medically appropriate.  All told, the requested Otezla therapy 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 dermatology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a laminectomy for treatment of his medical condition. Findings:  Two physician reviewers found that this man has chronic headaches.  His headaches have been non characteristic, frontal only in location, without an occipital or cervical component and without autonomic features.  Based on the medical records, the diagnosis of intracranial hypotension has not been established.  There is a lack of evidence of cerebrospinal fluid leak to establish a diagnosis or cause of intracranial hypotension.  He has no localizing features to implicate the thoracic level or any arachnoid cyst as his pain generator or the cause of his complaints.  All told, the requested laminectomy is not likely to be of greater benefit than other treatment options.  Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in neurological surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a leukocyte histamine release test (LHRT) for evaluation of her acute hives.  Findings:  Three physician reviewers found that the quality and quantity of data in the current peer-reviewed scientific medical literature is inadequate to establish the clinical utility or efficacy of this test for this patient.  Most cases of chronic urticaria do not have an identifiable cause. History and physical examinations are often enough to make the diagnosis and treat patients.  According to current management guidelines for chronic urticaria, even though chronic autoimmune urticaria can be differentiated from chronic idiopathic urticaria by the presence of auto-antibodies, the etiologic, therapeutic and prognostic value of this auto-antibody has not been established.  For this reason, chronic idiopathic urticaria should require no further evaluation with blood tests. Therefore, in light of present evidence and clinical information, along with the submitted records, the LHRT was not likely to be more efficacious than standard therapy.   Final Result: Three reviewers determined that the service 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:  One reviewer is board certified in dermatology and is actively practicing,   Two reviewers are board certified in allergy and immunology 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 Sovaldi and Daklinza for 12 weeks for treatment of her 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 and the Infectious Diseases Society of America, 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. Per guidelines, treatment-naive genotype 2 patients should be treated with Sovaldi and ribavirin for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA) approved for all patients with chronic hepatitis C, genotype 2 regardless of fibrosis stage.  The guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients (Sovaldi and Daklinza are recommended for ribavirin-ineligible patients only).  No medical contraindications are presented to support ribavirin ineligibility.  For these reasons, treatment with Sovaldi and Daklinza for 12 weeks is not supported as medically necessary for the treatment of this enrollee's hepatitis C infection. Final Result: The reviewer determined that the requested medications 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Anser IFX testing for the treatment of Crohns Disease.Findings:  Three physician reviewers found that the Anser IFX test was ordered to direct the use of infliximab in this patient with Crohns disease.  However, the use of Anser IFX to direct subsequent management has not been clinically proven to improve patient clinical outcomes or alter patient management in controlled clinical trials. The presence of antibodies alone does not necessarily result in loss of response to infliximab, nor have threshold 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.  Based on the clinical literature, the Anser IFX testing performed was not likely to be more beneficial for evaluation of the patients medical condition than standard management.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: Reviewers 1, 2, and 3 are board certified 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 breast examination. Findings:  Two 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. 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. Based upon the information set forth above, the services at issue were 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested inpatient hospitalization services for treatment of the enrollees behavioral health condition.   Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  The patient was compliant with nutrition in a liquid form, and had gained an adequate amount of weight to be safe for discharge.  She was medication compliant and was not a behavior problem.  The psychologists notes indicate that she has made progress in becoming more engaged with staff and peers.  She has also started performing her activities of daily living with minimal supervision.  Per the medical records, inpatient hospitalization was initially medically indicated.  However, the records fail to demonstrate the medical necessity of subsequent inpatient hospitalization.  There is no indication from the treatment plan that further improvement could be realistically expected.  The treatment provided continued with no change in the strategy that was used.  In sum, inpatient hospitalization was initially medically indicated, but not thereafter.  Final Result: The reviewer determined that a portion of the services at issue were 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 with sub-specialty certification in child and adolescent 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 inpatient psychiatric hospitalization services for treatment of his behavioral health condition. Findings:  The physician reviewer found that although the patient is diagnosed with a formal thought disorder and has history of non-adherence, the medical record does not support the medical necessity of inpatient level of care.  Per the submitted records, the patient had begun to improve. The notes indicate the patient expressed better insight into his illness and need for treatment. The psychiatrist stated that the patient was not a danger to himself or others. The patient was tolerating his medication with no noted side effects. The notes state that the patient was doing well on his current medication and it was also noted that the patient indicated that he was doing fine. There were no acute issues and both suicidality and homicidal ideation were absent. The patient was noted to have no behavioral issues and he reported that he was feeling better. The patient felt as though he was doing well and he had no anxiety or depression. The psychiatrist determined that he posed no risk to self or others. The nursing notes described a similar reassuring trend. For example, the patient was noted to be isolative; however, his affect, thought processing and thought content were described as appropriate. The patient denied paranoid ideation or auditory hallucinations and felt relaxed.   Further observed and noted were the following: the patient was sleeping 4-6 hours; his activities of daily living and ambulation were fully independent; and the patients mood was described as euthymic. In sum, the record indicates that the illness burden that had initially prompted the patients hospitalization had improved significantly. The patient was stable on medication and independent in functionality. There was no evidence of an acute psychiatric syndrome or medical crisis. Thus, continued inpatient psychiatric hospitalization was no longer medically necessary.  Final Result: The reviewer 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 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 a computerized axial tomography (CAT) scan of the head, magnetic resonance imaging (MRI) of the neck, MRI of the knees and MRI of the feet for evaluation of her medical condition.  Findings:  The physician reviewer found that there is a lack of support for the requested services in this clinical setting.  This patient has had chronic symptoms referable to her wrists.  In this case, the most appropriate consultations that the patient has had have been with the rheumatologists.  She has had extensive evaluation, and there has been no indication that she had a systemic process that would warrant advanced testing.  She has also not had basic imaging such as x-rays of the knees, cervical spine, or feet. This patient has no symptoms or signs indicating that there is a structural brain abnormality.  While CAT scans of the brain may be performed for ill-defined symptoms, the yield on those studies is exceedingly low.  There is a lack of support for the requested services in this clinical setting.  All told, the requested CAT scan of the head, MRI of the neck, MRI of the knees and MRI of the feet are not medically indicated for the evaluation of this patient. Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.   Credentials/Qualifications:  The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a water circulating cold pad with pump for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the equipment at issue.  Adie and colleagues noted that potential benefits of cryotherapy on blood loss, postoperative pain, and range of motion may be too small to justify its use, and the quality of the evidence was very low or too low for all main outcomes.  Kraeutler and colleagues compared compressive cryotherapy versus icepacks on postoperative patients undergoing arthroscopic rotator cuff repair or subacromial decompression.  The authors reported that there does not appear to be a significant benefit to the use of compressive cryotherapy over standard ice wrap in this setting.  Therefore, the water circulating cold pad with pump was not likely to have been of greater benefit than other treatment options in this patients case.  Final Result: Two reviewers determined that the equipment at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in orthopedic surgery and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested genetic sequencing for periodic fever syndrome. Findings:  Three physician reviewers found that this patient has an unknown inflammatory disease and while the genetic sequencing for periodic fever syndrome and autoinflammatory disease is not 100% sensitive, medical studies support the use of this test for this patient. Medical studies have shown that genetic sequencing may help distinguish between diagnoses such as, tumor necrosis factor receptor-associated periodic syndrome (TRAPS); Familial Mediterranean fever (FMF); Hyper-IgD syndrome (HIDS); periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis (PFAPA), to name a few. These are usually pediatric conditions; however, these conditions can occur in adults and can be difficult to diagnose. As in this case, most rheumatologists would obtain testing when they are unsure of the diagnosis and are considering treatment options. Many patients with autoinflammatory disease have a heterogeneous disease course and have incomplete symptoms so not all have the classic disease manifestation, thus making diagnosis difficult. The use of genetic sequencing may provide a definitive diagnosis and may present a better option for the patient prior to initiating treatment. For all these reasons, genetic sequencing is likely to be more efficacious than standard methods of evaluating this patients periodic fever syndrome.  Final Result: Three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in rheumatology, 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of her medical condition. Findings:  Two physician reviewers found that  breast tomosynthesis was not likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. There is insufficient peer-reviewed literature that supports the use of three-dimensional breast tomosynthesis compared to currently available techniques. Although digital breast tomosynthesis is a promising tool in breast imaging, further evidence is needed to establish its place in breast cancer diagnosis and screening. As such, the breast tomosynthesis performed was not likely to be more beneficial for evaluation of this patients condition than standard modalities. Final Result: Two 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are 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 Sovaldi for 24 weeks for treatment of his hepatitis C.  Findings:  The physician reviewer found that according to joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines recommend an interferon-free Sovaldi regimen and an interferon-containing Sovaldi regimen for non-cirrhotic treatment-naive patients with hepatitis C, genotype 3 (Sovaldi and Daklinza for 12 weeks or Sovaldi/peg-interferon/ribavirin for 12 weeks).  For patients who are ineligible for Daklinza or interferon, the guidelines recommend Sovaldi and ribavirin for 24 weeks as an alternate regimen.  The guidelines recommend Sovaldi and ribavirin last because it proved to be less effective than Sovaldi/peg-interferon/ribavirin in the BOSON trial.  Although hepatitis C treatment is needed in this case, no reason is provided to use Sovaldi and ribavirin rather than the regimens recommended by the current guidelines.  For these reasons, the requested treatment with Sovaldi for 24 weeks is not medically necessary for the treatment of this patients hepatitis C infection. 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 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.