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 the enrollees medical condition.  Findings: Two physician reviewers found that the patient was evaluated with screening mammogram and breast tomosynthesis.  The Health Plan has denied the tomosynthesis portion of the examination as investigational.  Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Tomosynthesis was also approved by Centers for Medicare and Medicaid Services (CMS) for reimbursement. The American College of Radiology (ACR) recommended that the technique be removed from the investigational category due to the advantages this tomographic method brings to radiologists interpreting mammograms. This procedure often allows the reader to separate dense glandular elements from underlying architectural distortion/mass resulting in a decrease in callbacks and increase in detection of small cancers. For these reasons, the addition of tomosynthesis to the usual two dimensional imaging mammographic protocol was likely of more benefit to this patient than if the examination had been performed using the two dimensional technique alone.Final Result: Two physician 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.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis  for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that  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 increase in diagnostic accuracy in detection of small cancers compared to two-dimensional imaging alone.  This modality has been determined to be of particular benefit to patients with heterogeneously or extremely dense tissue. Final Result: All three 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: Physician reviewers number one, two, and three 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for repeat treatment of Harvoni for 12 weeks with ribavirin for treatment of the enrollees medical condition. Findings:  The physician reviewers found that according to the 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. The AASLD and IDSA guidelines do not specify a course of action for genotype 4 patients who have failed Harvoni. For genotype 1 patients who have failed Harvoni, and are without NS5A resistance, Harvoni and ribavirin for 24 weeks is recommended.Final Result: Two of three reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: Physician reviewers number one, two, three 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and Daklinza for treatment of her hepatitis C virus.  Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to nonliver-related conditions. In treatment-naive genotype 3 patients, therapy is recommended with Sovaldi/Daklinza for 12 weeks. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and Daklinza is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Zepatier for treatment of the enrollees chronic hepatitis C virus genotype 1b. The Health Plan has denied Zepatier on the basis that Zepatier is not medically necessary without documentation of failure of or contraindication to formulary alternatives including Harvoni and Sovaldi. 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. The guidelines recommend that treatment-naive genotype 1b patients should be treated with regimens including Harvoni for 12 weeks or Zepatier for 12 weeks. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al; Zeuzem, et al). However, there are no controlled direct-comparison trials showing that Zepatier is safer or more effective than Harvoni for treatment of genotype 1 hepatitis C. For these reasons, although treatment of hepatitis C is needed in this case, treatment with Zepatier for 12 weeks is not supported as medically necessary.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.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested magnetic resonance imaging for evaluation of the enrollees severe major osteoporotic fracture. Findings: The physician reviewer found that there is sufficient support in the medical literature for the requested services in this clinical setting. Studies have shown that at autopsy, as many as 90% of patients with cancer have evidence of spine involvement. A common primary carcinoma, which metastasize to the spine, is breast cancer. Thoracic spine is the most common site of metastasis followed by lumbar and cervical spine. Plain radiographs often fail to detect spine involvement. MRI should be considered for patients with localized back pain of at least six weeks duration, particularly in patients with history of cancer or night pain. This patient has night pain in addition to a prior history of documented carcinoma of the breast. These two criteria of history alone justify obtaining an MRI for further evaluation of this patients medical condition. The need for both thoracic and lumbar studies is dictated by the fact that non-contiguous metastases are common. Moreover, the presence of pain in patients with osteoporosis is unusual unless there are acute pathological fractures present. In summary, the requested MRI is medically necessary and appropriate for this patient.  Final Result: The reviewer determined that the requested services are medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested inpatient mental health and inpatient electroconvulsive therapy (ECT) services for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that In this case, the patient was suffering from a formidable illness burden. Her mood disorder was complicated by cannabis use and anxiety. The anxiousness was of particular relevance since it has been well-established in clinical practice and the medical literature, that anxiety-ridden mood disorders without the complication of addictive illness are difficult to treat and in general have poorer outcomes. The patient was started on a transdermal antidepressant medication. She had suicidal thoughts and was noted to be very depressed. The treatment plan recommended discharge and completion of ECT as an outpatient. The medical literature supports ECT as a safe, rapid and highly effective neuromodular intervention available for the treatment of severe affective illness, including both unilateral depression and bipolar disorder. The intervention is endorsed by the American Psychiatric Association as a first-line treatment for depressive episodes. This course of treatment was safe, appropriate and consistent with good medical practice. In sum, considering the patients affective impairment with lingering anxiety and suicidality, both the inpatient setting and ECT were reasonably expected to improve the patients condition and prevent a more serious episode of illness. Additionally, the setting and therapy were safe, appropriate and consistent with good medical practice and thus medically necessary. 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found that 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 increase in detection of small cancers.  This modality has been demonstrated to be particularly of benefit for patients with dense breast tissue.  Final Result: All three 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition.  Findings:  The physician reviewers found that screening with both MRI and mammography might rule out cancerous lesions better than mammography alone in women who are known or likely to have an inherited predisposition to breast cancer.  The data support an essential role for screening MRI in women with an increased risk for breast cancer.  Final Result: All three 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a breast tomosynthesis for evaluation of the enrollees medical condition.  Findings:  The physician reviewer found that 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.   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. Final Result: Two of the three 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: Physician reviewers number one, two, and three 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:  The parent of an enrollee has requested air ambulance service for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that the air ambulance service was not medically necessary for treatment of the patients medical condition. In general, air transport is considered medically necessary when there is significant risk of decompensation with other forms of transportation, or when accessibility is an issue. In this case, the patient was having near syncopal episodes for a few days prior to seeking medical attention. While hospitalized at the treating facility, the patient was stable and had no further near syncopal episodes. In addition, a comprehensive work-up was negative. As such, the requested air ambulance service has not been established as medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the service at issue was 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 pediatrics and pediatric critical care 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 residential treatment center (RTC) services for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Modern psychiatric practice aims to place patients in the least restrictive treatment setting to optimize treatment gains and foster autonomous resilience.  In this patients case, she did not have a psychiatric condition that necessitated a 24-hour supervised setting.  She was neither psychotic nor suicidal.  She was adherent with her medications and had just started an anti-craving agent.  Upon presentation, the patients body mass index (BMI) was well within normal limits.  She had no significant medical issues.  The patient struggled with food rituals and adherence to the meal plan, but she was active in treatment and motivated for recovery.  Further, she had a supportive spouse and safe residence while the extent and outcome of less restrictive interventions during the episode of illness were unclear.  This patient required comprehensive treatment to address her eating disordered schemas, anxiety, addiction, and mood.  However, treatment in a 24-hour supervised setting was not for the 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested the Prometheus IBD sgi diagnostic test for evaluation of his medical condition.  Findings:  Two physician reviewers found that per the American College of Gastroenterology (ACG) guidelines for ulcerative colitis, the specificities of tests such as the Prometheus IBD sgi diagnostic test may make these assays useful in patients in whom no other clinical or pathologic features allow a diagnosis of ulcerative colitis or Crohns colitis (Kornbluth, et al). The ACG guidelines further state that the distinction between IBD and other diseases have important consequences in terms of counseling, prognosis, and the choice of medical and surgical therapies. Prideaux and colleagues noted that in 10-15% of patients with IBD who cannot be diagnosed accurately may benefit from a panel evaluating serologic markers given the diagnostic uncertainty. Plevy and colleagues found that other markers in the panel have proven utility in discriminating IBD from non-IBD. Given this patients diagnostic uncertainty, the Prometheus IBD sgi panel 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 testing at issue was likely to be more beneficial for evaluation of the enrollees medical condition than any available standard therapy.  Credentials/Qualifications:   All three 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested epidural steroid injection for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the medical necessity of the requested services.  This patient has pain complaints and physical examination findings that are corroborated by MRI studies.  He has failed to respond to conservative measures including physical therapy, massage therapy, medications and rest.  The current medical evidence supports the requested epidural steroid injection in this clinical setting.  All told, the requested epidural steroid injection is medically necessary 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 anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.