Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the standing frame, E1399 Easy Stand Evolve E3 Medium frame for treatment of the enrollees cerebral palsy.  Findings:  The physician reviewers found that the medical literature is inconclusive with respect to interventions such as standing frames to address health and functional issues in the setting of neurological disorders such as cerebral palsy. There is a lack of high-grade evidence to support the use of a passive standing device significantly improves health or functional outcomes. There is also a lack of scientific data in the peer-reviewed literature to support that standing frames provide other clinically significant benefits with respect to other health outcomes in the setting of these types of conditions.  Final Result: Two of three reviewers determined that the requested equipment 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, and three are board certified in physical medicine and rehabilitation 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for metal toxicity test. Findings:  The physician reviewer found that the medical literature is limited as to case reports of heavy metal toxicity from the release of nickel from a birth control implant device or in cases of nickel contact allergen sensitization.  Metal toxicity testing is not a useful or confirmatory test for the evaluation of the patients medical condition. Moreover, this type of test cannot fully explain the constellation of symptoms experienced during the implantation of the birth control device. Current guidelines and recommendations for symptomatic patients with a positive patch test to metals are lacking. The decision regarding implant revision following positive patch results can only be made after a thorough discussion between the patient and the treating provider.  In this case, the identification and avoidance of contact with the presumed offending agent, the birth control implant, by the patient was the key to successful resolution of her symptoms. The Practice Parameter Guidelines on contact dermatitis suggest that recovery is possible if the agent is identified and avoided. Given the symptom resolution, no further intervention is needed in this case. The symptoms reported by the patient, which included vaginal burning, fatigue, head and neck pain, are non-specific for contact allergy to nickel or another heavy metal, such as copper. Not having pre-implant metal toxicity levels to compare to, this renders post-implant metal toxicity levels a challenge to interpret and inconclusive.  Apart from contact with a birth control implant device, heavy metal exposure, to either nickel or copper, can be derived from a variety of different sources, including dietary, inhalation, or orthodontia.  Therefore, a direct link of metal toxicity to a birth control implant cannot be determined. 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 allergy and immunology 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: The parent of an enrollee has requested reimbursement for an echocardiogram. Findings:  The physician reviewer found that According to the current medical literature, heart murmurs are common in the pediatric population in otherwise healthy children. Typically they result from normal blood flow through the heart and great vessels. A murmur may also be the only indication of structural heart disease. In evaluating a child with a heart murmur, a detailed history must be obtained and physical examination performed. Historical findings such as feeding difficulty in infancy, shortness of breath, fatigue, and chronic cough, chest pain, and syncope may be present. There may also be a family history of congenital heart disease. Physical examination may reveal abnormal breath sounds such as crackles, hepatomegaly, abnormal peripheral pulses, heart murmur with characteristic location and/or duration, and edema. Characteristics most likely associated with an innocent murmur include systolic timing, soft sound, short duration, and low pitch quality, varying intensity with phases of respiration and posture, as well as murmurs that become louder during exercise or anxiety. The most common innocent murmur is called the Still murmur, which is thought to represent vibrations of the left outflow rest. This patients clinical information provided for review report that she was born prematurely, but there is no indication that she has abnormal vital signs, cyanosis, or poor growth. Further, the character and location is the murmur was not described by the provider. Further, there is no reason to expect a child born prematurely to be more likely to have a heart murmur than a child born full term unless there were additional abnormalities. 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 pediatrics with sub-specialty certification in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested prednisone for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation supports the requested medication in this patients case.  The records suggest a potential chronic inflammatory demyelinating polyneuropathy (CIDP) presentation primarily with pain and autonomic dysfunction, compounded by functional, non-organic overlay.  He has had some relief with intravenous immunoglobulin.  The medical evidence indicates that steroids can be effective for CIDP.  In this clinical setting, a trial of prednisone is medically appropriate, although the patient should be aware of potential long-term side effects.  There is sufficient support for the requested medication in this clinical setting.  In sum, prednisone is medically indicated for the treatment of this patient.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 physician reviewer is board certified in neurology 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 Sovaldi and ribavirin for treatment of the enrollees chronic hepatitis C virus genotype 1a and 2b.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This treatment guideline applies regardless of fibrosis stage or viral load. Per guidelines, when multiple genotypes are present, therapy should be chosen to maximize efficacy against each genotype. In this case, the patient was already treated with Sovaldi and Ribapak, as Sovaldi is a component of the Harvoni that was provided. Thus, the patient was appropriately treated for genotype 1 hepatitis C with Harvoni (Kowdley, et al). The genotype 2 infection may be cured, as Sovaldi with Ribapak can cure genotype 2 infection in cirrhotic patients (Zeuzem, et al). The patients viral load testing should be performed after treatment concludes in order to establish if has been cured. However, this information is not provided for review. Additionally, the requested regimen of Sovaldi and ribavirin for 12 weeks is no longer recommended by the AASLD and IDSA guidelines as an appropriate regimen for genotype 2 hepatitis C, as alternatives have proven statistically superior in effectiveness. In summary, evidence of ongoing hepatitis C infection is not provided, and the requested regimen would not be appropriate even if this patients hepatitis C persisted. For these reasons, the requested Sovaldi 400 mg tablet and ribavirin 600 mg tablet are not supported as medically necessary.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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1a.  Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated with Harvoni for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines also cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks 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 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 in-home vasopneumatic compression device for treatment of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medically necessity of the requested in-home vasopneumatic compression device for treatment of the patient's medical condition. The documentation states that the patient has a diagnosis of lymphedema, but the submitted records fail to reveal objective documentation of lymphedema in the bilateral lower extremities on physical examination. There are no therapy notes included for review with objective measurements of limb measurements and objective response to conservative therapy. A provider progress note indicates that the patient has a diagnosis of lymphedema but the records do not reveal physical exam findings of both lower extremities lymphedema. Additionally, the documentation from the lymphedema clinic indicates that the patient had a positive response to decongestive therapy with reduced circumferential measurements. These clinic notes conflict with a physician documentation which states that these measures no longer control the patients condition. Given the documentation of a positive response from the lymphedema clinic to decongestive therapy, it is unclear that the patient has failed a self-management program recommended in the medical literature that includes self-lymph drainage, home lymphatic exercises, a skin care regimen, and compression garments or bandages as recommended by the National Lymphedema Network prior to requiring a compression device. For all of the aforementioned reasons, the requested in-home vasopneumatic compression device is not medically necessary for treatment of this patient.Final Result: The reviewer determined that the requested device is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in physical medicine and rehabilitation with sub-specialty certification in neuromuscular medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral 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 compared to standard mammography alone. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of the enrollees chronic hepatitis C virus genotype 1b.  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 all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1b patients should be treated with Harvoni. These 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 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni 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 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 laboratory testing to re-evaluate the diagnosis of biotin synthetase deficiency (holocarboxylase synthetase gene) for evaluation of the enrollees diagnosis of carboxylase synthetase deficiency. Findings: The physician reviewer found that based on the records provided for review, the patients presentation is not consistent with carboxylase synthetase deficiency. Holocarboxylase synthetase would not present around nine years of age, as it would typically be symptomatic before three months of age without treatment. Biotinidase deficiency is similar and could be symptomatic after three months of age if not treated. However, both of these conditions are screened for in newborns. The treatment for biotinidase deficiency is about 10 mg of biotin per day while for multiple carboxylase deficiency it is higher. This patients symptoms are reported to respond to biotinidase treatment. Thus, enzyme testing may be appropriate, but there is no role for genetic testing in this clinical setting. Accordingly, the requested laboratory testing to re-evaluate the diagnosis of biotin synthetase deficiency (holocarboxylase synthetase gene) is not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested testing 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 internal medicine with sub-specialty certification in medical genetics 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 breast magnetic resonance imaging (MRI) for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that this patient has heterogeneously dense tissue on mammography which is known to limit the usefulness of standard mammography. The pathologic diagnosis of cellular atypia is a finding most pathologists consider to be a pre-malignant lesion. A detailed screening exam to evaluate for more advanced disease such as ductal carcinoma in situ (DCIS) is clinically indicated. MRI is the most sensitive means to evaluate the remainder of each breast in light of the pre-malignant nature of the biopsy material. Therefore, the breast MRI has been established as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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 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 authorization and coverage for sleeve gastrectomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  This patient has a history of morbid obesity and underwent Lap-band surgery.  This needed to be emergently removed secondary to complication of slipped band. The Lap-band, unlike other metabolic bariatric procedures is a foreign body and when removed no longer leaves any permanent tool for weight loss.  Therefore, the natural history is that these patients may ultimately regain weight without a more durable metabolic bariatric procedure.  In this patients case, her body mass index is slightly under 35, and she has hypertension.  However, proceeding with the sleeve gastrectomy cannot be recommended at this time.  The records do not document an updated dietary clearance to ensure that this patient understands the dietary consequences and risks and is considered behaviorally to be aware of the risks and determined to be an appropriate candidate.  Standard primary guidelines for bariatric surgery recommend a complete thorough multidisciplinary evaluation including dietary clearance.  In sum, the requested sleeve gastrectomy is not medically indicated for the treatment of this patient.  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 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.