Persius/hicric huggingface dataset:
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 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.  In this patients case, her breasts were described as extremely dense.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Final Result: Two of 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Praluent 75 mg/ml SQ every two weeks for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical records document significantly increased coronary risk, but no symptoms or objective findings indicative of coronary vascular disease and no confirmed diagnosis of homozygous or heterozygous familial hyperlipidemia.  These diagnoses require not only elevated LDL levels that significantly exceed 180 mg/dl, but also a combination of physical examination findings (arcus cornealis below the age of 45, tendon xanthomata), a family history of premature coronary disease (younger than 50 years in second-degree relatives or aged younger than 55 to 60 years in first-degree relatives) and documented genetic defects related to cholesterol metabolism according to published criteria.  The documentation does not support the patient meets criteria for this diagnosis.  Praluent is a PCSK9 inhibitor studied in and approved for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL cholesterol.  This patient does not meet any of those criteria.  PCSK9 inhibitors have not been studied in other patient populations, such as this patient.  Current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  Therefore, the requested Praluent 75 mg/ml SQ every two weeks is not medically indicated 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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in cardiovascular 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for 24 hours or more of licensed vocational nurse (LVN) services a week and one hour per month of registered nurse (RN) supervision for treatment of the enrollees achondroplasia, autism, left eye blindness, single kidney, developmental delay, and feeding problem with gastrostomy tube. Findings:  The physician reviewer found that that this patient has been stable without any complications of chronic medical conditions. Further, the patient does not require a skilled nurse for care of a feeding tube. Care for a gastrostomy tube can be taught to a non-medical person for administration of medications and nutrition. Overall, the patinet's needs are custodial in nature and do not require the services of a skilled nurse. 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 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 weekly individual therapy for treatment of the enrollees behavioral health conditions. Findings: The physician reviwer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  The patient was not a danger to himself or others.  He had improved in his treatment and reported good control.  Per the medical records, his relationship with his biological mother and stepmother improved.  He became more motivated and future-oriented.  Based on the clinical documentation, the patient could continue treatment at his current level of care with additional reinforcement provided by group therapy, as well as telephone contact with his providers.  All told, the requested weekly individual therapy 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 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 for skilled nursing facility (SNF) services with physical therapy and occupational therapy for treatment of the enrollees right distal radius fracture.  Findings: The physician reviewers found that the requested SNF services with physical therapy and occupational therapy were not and are not medically necessary for treatment of this patients medical condition. The documentation does not reveal that the patient requires skilled nursing or skilled rehabilitation on a daily basis or at least five days per week. The patients current functional status is at a level that she can be safely discharged to home with outpatient therapies and caregiver support if needed. The patient can transition toward a goal of an independent home exercise program. The patient has no acute, uncompensated medical issues that require a SNF level of care. She is medically stable and can follow-up as an outpatient as indicated with her providers for care including monitoring of anticoagulation, renal status, diabetic and pain management as needed. The patients current medical and rehabilitation needs can be safely met at a lower level of care. Thus, the SNF services with physical therapy and occupational therapy were not and are not medically necessary for treatment of this patients medical condition.Final Result: The reviewers 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested colonic manometry procedure for evaluation of the enrollees chronic constipation, outlet constipation, and concern for slow transit constipation.  Findings: Two physician reviewers found that in the peer-reviewed medical literature, one study of patients with refractory constipation who were referred for colectomy were evaluated with colonic manometry (Singh, et al). The testing differentiated between patents with colonic neuropathy and colonic myopathy. Patients with normal manometry did poorly with colectomy, but did well with conservative management. The study concluded that colonic manometry was useful for determining pathophysiology and for guiding management in this patient population. The American Gastroenterological Association (AGA) guideline on constipation states that colonic intraluminal testing such as colonic manometry should be considered to document colonic motor dysfunction before colectomy (Bharucha, et al). In this patient, with medically refractory constipation who may require colectomy, the requested colonic manometry procedure is likely to be more beneficial for evaluation than any available standard testing.Final Result: Two physician reviewers determined that the requested diagnostic procedure is 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Norco 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 medication.  There is a lack of support for chronic use of short duration opiates for osteoarthritis.  The use of chronic opiates requires a separate assessment of risk, urine toxicology screening, the formulation of a plan to assess progress and the execution of an opiate maintenance agreement.  The records do not document these requirements in this patients case.  The current medical evidence does not support Norco in this clinical setting.  The use of Norco for over 16 weeks has not been intensively studied for safety and ongoing efficacy.  Therefore, the requested Norco is not medically indicated 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 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. However, in this case there were no problems to be resolved. The patient did not have dense breasts, she did not have a mass, there were no palpable lumps, and she did not have suspicious calcifications. A routine mammogram would have been sufficient in this clinical setting. Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there has been no change when compared to prior mammograms. Therefore, the breast tomosynthesis was not 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 not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in 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 authorization and coverage for Harvoni for eight weeks 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 for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. The AASLD and IDSA guidelines cite data showing reduced survival with delayed treatment. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for brand name Topamax, (not a generic such as topiramateary) for treatment of the enrollees localization related focal epilepsy with complex partial seizures.  Findings:  The physician reviewer found that while generic antiepileptic drugs are appropriate for many patients with epilepsy, there are some patients that are highly sensitive to very small changes in drug preparations. In such cases, patients may have breakthrough seizures when a different generic therapy is substituted for another. In this particular case, this patient has been documented to have breakthrough seizures when generic antiepileptic drugs therapies were utilized. Since persistent seizures cause significant morbidity, it is medically reasonable to use a brand name antiepileptic drug such as Topamax to limit drug level fluctuation and lower this patients risk of seizures. Thus, the requested brand name Topamax, (not a generic such as topiramate), is supported as medically necessary for treatment of this patients epilepsy.  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: Physician reviewer number one is board certified in internal medicine and 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 authorization and coverage for Humira Pen for the treatment of the enrollees medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient was intolerant of methotrexate and is reported to have failed treatment with Otezla.  However, the medical records fail to demonstrate how long the trial of Otezla was prior to stopping.  The records do not document a trial of injectable methotrexate.  The severity of the skin disease is not known, and the severity of the arthritis appears to be mild per the records.  Methotrexate is the preferred agent in psoriatic arthritis.  The records fail to demonstrate that the patient has failed the preferred non-biologic agents for her disease, and the Health Plans requirement that the patient try at least 12 weeks of dose optimized, oral DMARD therapy is medically appropriate.  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: Physician reviewer number one is board certified in internal medicine with sub-specialty certification in rheumatology 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 residential treatment center (RTC) services for treatment of the enrollees alcohol use disorder. Findings:  The physician reviewer found that based on the records provided for review, this patient appeared to have post-acute withdrawal symptoms and he was on Campral. However, he was not a danger to himself or others, he was medically stable as his hypertension was controlled on medications, and the patients elevated creatinine did not require 24-hour monitoring. Further, the patient was not seen by a physician after the initial evaluation, there are no nursing notes, there is no treatment plan, and there are only American Society of Addiction Medicine (ASAM) criteria evaluations. These are not considered treatment plans with updates which are individualized for the patients particular needs. 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 with sub-specialty certification in addiction 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 Ambien for treatment of the enrollees sleep disorder. Findings:  The physician reviewer found that Current American Academy of Sleep Medicine guidelines and the medical literature regarding the treatment of circadian rhythm sleep disorders do not recommend the use of any sedative hypnotic agents.  The guidelines did not recommend the use of sedative hypnotic agents, particularly Ambien, noting that the research conducted showed no clinical benefit to next day functioning.  Furthermore, a higher rate of adverse events were noted with Ambien when compared to other therapies. In regards to the management of insomnia in general, particularly chronic insomnia, current evidence based research and practice guidelines recommend the use of non-pharmacological interventions. Moreover, non-pharmacological approaches have been shown to have equivalent benefit over time when compared to the use of pharmacological agents.  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: Physician reviewer number one 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 a panniculectomy for treatment of the enrollees medical condition. Findings:  The physician reviewer found that the medical documentation does not support that the patient has evidence of a significantly overlapping abdominal pannus. There is evidence of rashes but the only conservative management documented is baby powder. No other treatments were documented including medicated powders, antifungal treatment or antibacterial treatment. In addition, primary care evaluations did not document any history of rashes or dermatologic treatment. Finally, the photographs and evaluation by the requesting surgeon only note evidence of a small overhanging abdominal pannus.  Based on the entirety of the documentation submitted, a clear functional deficit that has failed standard dermatologic treatment and is associated with a significantly overhanging pannus have not been adequately defined. Final Result: The reviewer determined that the requested procedure is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one is board certified in plastic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.