Persius/hicric huggingface dataset:
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 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 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 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.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 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 nonliver-related conditions. The guidelines recommend that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1 patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (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 12 week course of Harvoni 90-400 mg tablets is supported as 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 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 sleep study performed for evaluation of the enrollees excessive daytime sleepiness. Findings:  The physician reviewer found that while polysomnography has traditionally been used to evaluate obstructive sleep apnea (OSA), the medical literature and current studies support testing for OSA in the home environment. As a result, the standard practice at this time is to test patients with suspected OSA with unattended sleep testing.  Such testing has been shown to be equally beneficial in terms of the establishment of OSA in the lab testing. Moreover, unattended or in home sleep testing is a less resource intense environment. In this patients case, there was no documentation of any contraindications to unattended testing or home sleep testing. The patient had no complaints of limb movements. Given that there is clinical support in this diagnostic paradigm towards ambulatory testing and this patient had a previous established diagnosis of OSA, the sleep study performed was not medically necessary for the evaluation of this patient. Final Result: The reviewer determined that the services at issue were 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 neurology with sub-specialty certification in sleep medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Linzess 290 mcg (1 x day) for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the American Gastroenterological Association Medical Position Statement on Constipation states that after failure of an osmotic agent, and then a stimulant laxative, a newer agent such as Amitiza or Linzess should be used.  However, there is no documentation provided stating that an osmotic or stimulant laxative has been attempted for treatment of this patient.  Amitiza and Linzess both have a different mechanism of action than the aforementioned osmotic and stimulant laxatives. However, Linzess has not proven to be superior to Amitiza in a controlled clinical trial for either constipation-predominant irritable bowel syndrome or chronic constipation. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested anterior lumbar interbody fusion surgery for treatment of the enrollees chronic low back pain.  Findings: The physician reviewer found that the medical records do not show any evidence of lumbar instability, fracture, or tumor. Also, there are no flexion-extension x-rays showing more than 5 mm of abnormal motion at any lumbar segment. Lumbar fusion for degenerative disc condition is not more effective than conservative measures for low back pain treatment. This patients records do not demonstrate that conservative treatment has been exhausted. All told, the requested anterior lumbar interbody fusion surgery is not medically necessary for treatment of this patients low back pain.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.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 Pulmozyme and Cayston  for treatment of the enrollees bronchiectasis.  Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medications.  Cayston is U.S. Food and Drug Administration (FDA) approved for the treatment of patients with cystic fibrosis who have pseudomonas infection of the lung. Pulmozyme is FDA approved treatment for patients with cystic fibrosis.  It is used because of the specific abnormal sputum in patients with cystic fibrosis.  This patient had extensive genetic and other studies to rule out cystic fibrosis.  She does not have cystic fibrosis, and therefore has no FDA approved indication for either of the requested medications.  These medications have not altered her decreased lung function (increased airway obstruction).  There is a lack of support for the requested medications in this clinical setting.  All told, Pulmozyme and Cayston are not medically indicated for the treatment of this patient.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 pulmonary disease and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested intensive outpatient (IOP) services, at a minimum of four times a week 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 showed improvement in that he was better able to communicate with his peers, therapists, and parents. He demonstrated a better capability to effectively express his feelings and thoughts. The patient did require further treatment to continue to work on his coping and communication skills. The patient did not represent a threat to himself or others.  The patient was medically and psychiatrically stable. The patient was not psychotic or manic.  The patients problems with impulsivity and distractibility may have correlation between his substance abuse and ADHD. However, it was unclear from the submitted records why the patient was not seen by a psychiatrist for a psychotropic medication evaluation given the patients reported ADHD. In this patients case, the documentation does not support the treatment of four times per week at the IOP level of care.  Instead, IOP services, at two times per week, were medically necessary for treatment of this patient. The services were not and are not medically necessary.Final Result: The reviewer determined that a portion of the services at issue was and is medically necessary for treatment of the patients medical condition. Specifically, the IOP services, at two times per week, were medically necessary for treatment of this patient. The services forward were not and are not medically necessary. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested skilled nursing facility services for treatment of the enrollees medical condition status post multiple trauma injuries.  Findings: The physician reviewer found that the request for skilled nursing facility services have not been established as medically necessary in this clinical setting. The American Academy of Physical Medicine and Rehabilitation states that Medicaredefine[s] skilled services as when the inherent complexity of a service prescribed for a patient is such that it can be performed safely and/or effectively only by or under the general supervision of skilled nursing or skilled rehabilitation personnel. According to the documentation submitted for review, the patient has made excellent progress in self-care and functional mobility with skilled therapies. The patient is at a functional level and she does not require inpatient skilled therapy. She may need outpatient physical therapy and/or occupational therapy, but the records do not demonstrate a need for intensive skilled therapy. With time and healing of injuries she will regain weight-bearing status and mobility will improve further. Accordingly, further skilled nursing facility services are not medically for treatment of the patients medical condition.Final Result: The reviewer determined that the requested services 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral hip replacement surgery for treatment of the enrollees bilateral hip osteoarthritis.  Findings: The physician reviewer found that the records indicate that the patient is medically stable and bilateral hip replacement is indicated for her medical condition. The patients records do not suggest that she is unstable for surgery. Patients with hip osteoarthritis have high disability levels and substantially impaired health-related quality of life. Her nutritional indices are borderline, but have been stable over a number of months. Given her current medical issues, the patients nutritional status may not improve significantly. Total hip replacement is indicated in this patient with severe pain and disability who has exhausted conservative treatment, is medically stable, and a reasonable risk for undergoing major surgery. Accordingly, the requested bilateral hip replacement surgery is supported as medically necessary for treatment of this patients hip osteoarthritis.Final Result: The reviewer determined that the requested surgery 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 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 reimbursement and prospective authorization and coverage for weekly occupational therapy services for treatment of the enrollees impaired skills in grasp, coordination, and writing. Findings:  The physician reviewer found that the records provided for review indicate that this patients occupational therapy scores were not low enough to support occupational therapy services as medically necessary. The patients deficits are not severe enough to require medical intervention. The patient may be eligible for school based programs to improve her fine motor skills including handwriting. However, the patient does not have a congenital developmental disability to support an indication for occupational therapy. In addition, the patients fine motor delays are not far enough behind her peers to warrant occupational therapy services. 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 pediatrics with sub-specialty certification in developmental and behavioral 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested surgery (hemorrhoidectomy) for treatment of the enrollees painful hemorrhoids. Findings: The physician reviewer found that an enrollee has requested authorization and coverage for surgery (hemorrhoidectomy). The Health Plan has denied this request indicating that the requested surgery is not medically necessary for treatment of the enrollees painful hemorrhoids.  The requested surgery has not been established as medically necessary for treatment of the patients medical condition. Hemorrhoids are part of the normal anorectal anatomy and symptoms from hemorrhoids are common. The records do not include examination of the anal area, digital rectal exam and anoscopy. Initial medical management includes increasing the fiber in the diet and minimization of time spent with each bowel movement. If a patients symptoms do not improve with conservative medical management, then office based procedures such as rubber band ligation should be considered (Jacobs). The American Society of Colon and Rectal Surgeons (ASCRS) practice parameters for management of hemorrhoids states that the evaluation of patients with hemorrhoids should include a directed history focusing on symptoms, bowel habits, family history, and physical exam such as visual inspection, digital exam and anoscopy. In this case, there is no medical documentation to support that these were performed for this patient. The practice parameters also state that dietary modification with adequate fiber and fluid intake is the first-line non-operative therapy for patients with symptomatic hemorrhoids. Finally, the ASCRS further states that patients with grade I, II, or III hemorrhoids that fail medical management may be effectively treated with office-based procedures. Similar recommendations for initial diagnosis and management of hemorrhoids are made by the American College of Gastroenterology (Wald, et al). Given the lack of documentation showing history and physical examination, as well as trial and failure of conservative medical management, the request for hemorrhoidectomy is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in certified in colon and rectal 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 OxyContin 30 mg and OxyContin 40 mg for the treatment of the enrollees chronic pain.  Findings:  The physician reviewer found that the patient is on high dose opiates for post-laminectomy syndrome.  The Health Plan has denied coverage for OxyContin 30 mg and OxyContin 40 mg.  However, the patient was left without a viable plan for pain control.  The Centers for Disease Control and Prevention (CDC) guidelines describe the appropriate approach for treating patients in this clinical setting.  The authors noted established patients already taking high dosages of opioids, as well as patients transferring from other clinicians, might consider the possibility of opioid dosage reduction to be anxiety-provoking, and tapering opioids can be especially challenging after years on high dosages because of physical and psychological dependence.  Per the guidelines, providers should work with the patient to taper opioids to safer dosages, and providers should collaborate with the patient on a tapering plan.  The guidelines note that patients tapering opioids after taking them for years might require very slow opioid tapers as well as pauses in the taper to allow gradual accommodation to lower opioid dosages.  Thus, the current medical evidence does not recommended abrupt detoxification.  In this patients case, the provider needs to develop a treatment plan.  Until this plan is developed to safely taper these medications, the requested OxyContin 30 mg and OxyContin 40 mg are medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication dosages 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Orthovisc injections. Findings:  The physician reviewer found that there is medical justification for viscosupplementation treatment and even one-time re-treatment when specific criteria are met. However, there is insufficient evidence to show long-term benefit of multiple re-treatments with viscosupplementation injections of the knee. The benefit of more than two series of viscosupplementation injections has not been established in the scientific literature. In addition, multiple repeat series of viscosupplementation injections is not U.S. Food and Drug Administration (FDA) approved and is not considered medically necessary by Centers for Medicare and Medicaid Services (CMS). Final Result: The reviewer determined that the requested services 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 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.