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

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a chest computed tomography scan. Findings:  Three physician reviewers found that in recent years, there has been intensive studies concerning the merits of a screening program for lung cancer. The most notable and widely accepted study was performed by the National Lung Cancer Screening Team (NLST) a multicenter trial.  Their guidelines were published several years ago and the following patients are considered appropriate for low-dose screening CT scans: the patients should be between 55-74 years of age, have a heavy smoking history, as defined by at least 30 pack per year and either continue to smoke or have stopped smoking within the last 15 years. In the National Comprehensive Cancer Network (NCCN) pamphlet, they have stratified patients into patients at high, moderate, and low risk.  Final Result: Three reviewers determined that the the services at issue were not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three 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. Findings:  Three physician reviewer 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 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 particular patient, digital breast tomosynthesis offered the advantage of better delineating the mass, with the possibility of further characterizing it.  In addition, satellite or additional lesions might be better detected with tomosynthesis. In a patient with a mass detected on palpation, tomosynthesis is warranted, even if surgery would otherwise be performed, as the tomosynthesis could potentially broaden the scope of the surgery. Final Result: Three reviewers determined that the service 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for magnetic resonance imaging (MRI) of the left shoulder for evaluation of the enrollees shoulder pain. Findings:  The physician reviewer found that the documentation submitted for review does not support a medical indication for MRI of the left shoulder. The records do not demonstrate physical exam findings consistent with impingement or brachial plexus syndrome or suspicion for mass. In addition, the submitted medical records fail to demonstrate that the patient has tried and failed four weeks of conservative therapy. There is a lack of medical literature available that supports MRI in this clinical setting. All told, the requested MRI of the left shoulder is not medically necessary for evaluation of the patients medical condition. Final Result: The reviewer determined that the requested diagnostic procedure 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 diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for modafinil 200 mg, twice daily for treatment of the enrollees hypersomnia. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the requested medication.  The documentation noted idiopathic hypersomnia. The multiple sleep latency test revealed a mean sleep latency of eight minutes with no rapid eye movement sleep.  This is diagnostic of this condition.  Idiopathic hypersomnia is a clinical variant of narcolepsy and is treated the same way.  In both disorders, the mean sleep latency test reveals a mean sleep latency of less than 10 minutes.  In narcolepsy, there is rapid eye movement sleep documented.  In idiopathic hypersomnia, the sleep latency is identical, but there is no rapid eye movement sleep documented.  The requested medication is the generally accepted treatment for this patients condition.  All told, modafinil 200 mg, twice daily 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 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: The parent of an enrollee has requested authorization and coverage for 30 hours per week of direct applied behavioral analysis (ABA) therapy, 16 hours per month of supervision and four hours per month of parent training. Findings:  The physician reviewer found that one study reported that autistic children who respond to ABA therapy will show marked improvements in behavior after two years of therapy. In this case, the progress report shows multiple areas of improvement, the Vineland Adaptive Behavior Scales demonstrate that he is functioning between the 1st and 5th percentiles in language, living skills, and socialization despite over five years of intensive ABA therapy. The requested amount of ABA hours that include 30 hours per week of direct therapy, 16 hours per month of supervision and four hours per month of parent training will not likely improve his 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 pediatrics with sub-specialty qualification in child 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 surgery to extract a mass forming in the vagina for treatment of the enrollees prolapsed uterus. Findings:  The physician reviewer found that this patient presents with a prolapsed uterus. Pelvic relaxation and uterine prolapse is sometimes managed surgically, typically with a vaginal procedure, such as a vaginal hysterectomy and vaginal suspension, which requires the patient being in a high-lithotomy position with the legs flexed on the abdomen. Prolapse also can be managed non-surgically by placement of a pessary, which is an insert placed into the vagina that holds the uterus back into its natural position. The placement of a pessary is frequently successful, resolves the symptoms of prolapse, and avoids the risks of surgery. In cases where there are medical or orthopedic issues making surgery risky or challenging or impossible, this is an excellent option. In the medical literature, noted that first-line management of pelvic organ prolapse (POP) is conservative therapy. The author found that the mainstay of nonsurgical treatment for POP is the vaginal pessary. In this case, the providers documented that this patient cannot tolerate the high-lithotomy position necessary for vaginal surgery, so a pessary fitting is the next recommended step for this patient, and not surgery. For these reasons, the requested surgery to extract a mass forming in the vagina is not medically necessary for treatment of this patients uterine prolapse. 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 obstetrics and gynecology 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 Lyrica for treatment of the enrollee, who has been diagnosed with fibromyalgia. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  Regarding the stepwise approach to treatment of chronic pain associated with fibromyalgia, initiating therapy with a tricyclic is often the first step.  In patients with an inadequate response or with intolerance of a tricyclic, a serotonin-norepinephrine reuptake inhibitor or one of the anticonvulsants are recommended.  Monotherapy is recommended initially, and alternative drugs are added as the patient experiences symptoms.  In this patients case, the documentation does not support that the patient has failed treatment with gabapentin.  There is no objective documentation to support that the patient continues to have uncontrolled symptoms despite treatment with gabapentin.  All told, the requested Lyrica 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 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: A parent of an enrollee has requested authorization and coverage for continuation of speech and language therapy. Findings:  The physician reviewer found that according to a study  Empirical evidence exists for many of the different interventions in speech-language pathology. However, relatively little is known about the optimal intensity of those interventions. In this case, the patient been receiving speech therapy since October 2015. At the onset of speech therapy, testing indicated comprehensive language at five years and three months and expressive language of three year three month of age equivalency.  After one year of speech therapy repeat testing indicated similar scores. The records submitted for review demonstrate, that this patient has not had significant improvement in either expressive or speech comprehension after a year of speech therapy. Final Result: The reviewer determined that the requested therapy 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 pediatrics with sub-specialty qualification in child 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: The parent of an enrollee has requested reimbursement and prospective authorization and coverage for residential mental health treatment services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting. The patient was not a danger to himself or others. Although continuing to act out verbally, break boundaries, escalate arguments, and lack insight, the patient had shown improvement in all of these areas.  He was not aggressive or violent towards others.  He performed his ADLs and was cognitively intact. He did not show improvement in the area of school. However, this did not require the residential setting. This could perhaps be accounted for, at least in part, by his unmedicated state. He was medically stable, and his psychotropic medication management did not require the residential setting. The medication list had not reflected any changes. Although he continued to struggle with emotional lability and required ongoing intensive treatment to further develop coping skills, this did not require the structured environment of a 24-hour a day 7 days a week residential setting. The patient could have been treated at a lower level of care. In sum, the services at issue were not and are not medically necessary for treatment of this patient. Final Result: The reviewer determined that the services at issue were not and are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for digital breast tomosynthesis for evaluation of the enrollee, who was asymptomatic. Findings:  2/3 of the physician reviewers found that the patient had a screening mammogram including breast tomosynthesis.  This was followed by bilateral whole breast ultrasound.  The report noted no evidence of cancer.  The Health Plan has denied reimbursement for digital breast tomosynthesis performed.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient.  There is sufficient support for the service at issue in this clinical setting.  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 overall diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of tomosynthesis to the usual two-dimensional mammographic protocol was likely of greater benefit to the patient than had her mammogram been done with two-dimensional imaging alone. Final Result: 2/3 of the reviewers determined that the service 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: Physician reviewer number one is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number two is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.Physician reviewer number three is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for Afirma Gene Expression Classifier testing for evaluation of the enrollees thyroid nodule. Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Gene Expression Classifier test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures. Final Result: 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 the digital breast tomosynthesis for evaluation of the enrollees breast cancer screening.Findings:  Two physician reviewers found that  the patient has breasts that have been described as heterogeneously dense.  While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for bilateral digital breast tomosynthesis for evaluation of the enrollee, who was asymptomaticFindings:  All three 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, the records noted dense breast tissue.  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: Three reviewers determined that the service 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.