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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her breast exam.  Findings:  Two physician reviewers found that there is sufficient support for the services at issue in this clinical setting.  Per Skaane and colleagues, the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. Ciatto and colleagues state that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus, there is adequate literature supporting the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.  All told, breast tomosynthesis was likely to have been 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 likely to be more beneficial for evaluation of your medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested a Flexitouch Pneumatic Compression Device and garment for treatment of his medical condition. Findings:  The physician reviewer found that based on the documentation submitted for review, the requested services have been established as medically necessary. The patient received physiotherapy sessions with elevation, exercise, compression, wrapping, and compression stockings. He used a non-programmable pump for an extended period of time which did not fit well and was painful. According to the patients clinician, the non-programmable device was ineffective in treating the lymphedema. Moreover, the Flexitouch system has shown better outcomes in randomized clinical trials and other studies (Fife, et al; Muluk, et al; Ridner, et al). Progressive disease on the standard device has been sufficiently documented and the use of the Flexitouch device is medically appropriate and necessary. Given the above, the requested services are medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: The reviewer is board certified in medical oncology 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 shoe inserts and orthopedic footwear 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 equipment.  Per current guidelines, inserts and shoe modifications are medically indicated if they are on a shoe that is an integral part of a medically necessary leg brace, if they are medically necessary for the proper functioning of the brace.  There is a lack of support for the requested shoe inserts and orthopedic footwear in this patients case.  The shoes recommended by the provider appear to be standard over-the-counter sneakers, and the recommended insoles are also over-the-counter standard insoles.  All told, the requested shoe inserts and orthopedic footwear are not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the requested equipment 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 podiatry 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 in-home speech therapy per week; in-home occupational therapy evaluation and in-home sensory integration therapy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that review of the submitted documentation and medical literature fails to demonstrate the medical necessity of the requested services. There is ample evidence in the peer-reviewed literature that demonstrates applied behavior analysis (ABA) and early intensive behavioral intervention are effective for children with autism spectrum disorder (ASD) (Reichow, et al). There is also evidence that ABA can improve compliance and attention to adult-directed tasks (Ostfeld-Etzion, et al). Although the requested therapies are important, this patient is not likely to engage in the therapies at this time and thus will not be able to benefit. This requested therapies, are not indicated either in-home or out of the home. At this time, it is more beneficial for this patient to focus on ABA services. In addition, a preschool setting will likely assist with the patients ability to engage with adult-directed activities. A re-evaluation at a point in the future is indicated for the requested therapies to determine if the patient has the ability to engage in the proposed therapies. For the reasons stated, the requested therapies are not medically necessary in this clinical setting. Final Result: The reviewer determined that the requested therapies 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: The guardian of an enrollee has requested computed tomography (CT) scan of the abdomen for evaluation of the enrollees medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services. In this case, the patients symptoms are primarily functional, but with some contribution from gastroesophageal reflux, explaining the improvement that was described at the appointment while on high dose proton pump inhibitors. The degree of disability that the patient is experiencing, with numerous school absences, does not indicate an anatomic or inflammatory problem. Rather, as described by Assa and colleagues, functional pain can be just as disabling as organic conditions such as inflammatory bowel disease. Dhroove and colleagues reported on the low utility of testing in children with functional abdominal pain, including the use of abdominal ultrasound and abdominal CT. Given the above, the requested services are not indicated for the evaluation of the patients medical condition.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 pediatrics and pediatric 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested radioembolization (selective internal radiation therapy with resin microspheres) for treatment of her medical condition.  Findings:  Two physician reviewers found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. In general, radioembolization has durable response and tends to better tolerated than transarterial chemoembolization (TACE). There are a number of prospective and retrospective studies which document the safety and efficacy of Yttrium-90 embedded spheres. In addition, radioembolization is within the generally accepted professional medical standards as being safe and effective. Sato and colleagues investigated 137 patients who underwent 227 administrations of Yttrium-90 microspheres for liver metastases. Four of these patients had renal cell carcinoma.  For all lesions in all patients, 87% experienced a biologic response. In the study by Abdelmaksoud and colleagues, six patients with metastatic renal cell carcinoma underwent eight radioembolizations. After a mean follow-up of more than 2 years, three patients had a complete response, and one patient had a partial response. A case report Hamoui and colleagues describes a patient with good response and better than expected survival after radioembolization for renal cell carcinoma. For patients with bulky liver disease, with a lack of therapeutic options, who have previously undergone systemic therapy, treatment with radioembolization is clinically indicated. In this case, the patients quality of life can be substantially improved with liver-directed therapy. Moreover, liver directed therapy has a reasonable likelihood of preventing (or delaying) symptomatic progression. As such, the requested services are likely to be more beneficial for treatment of the patients medical condition than any standard treatments.  Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in radiation oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  The parent of an enrollee has requested partial hospitalization program level of care for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or others.  The patient required monitoring but did not require partial hospitalization program level of care to do so.  She was not aggressive towards others and was not psychotic or manic.  She was medically stable.  She was cooperative and compliant with her medications and suffered no side effects.  The patient continued to suffer from depression, anxiety, and obsessive thoughts around her eating disorder but this could have been managed at a lower level of care.  Her parents participated and received education.  Although motivated, the patient still struggled with compliance regarding exercise and required some supervision with her meal plan.  However, given the progress she had made, she no longer required the structure of monitoring at two meals and in between meals which would be provided in partial hospitalization program level of care.  Per the medical records, the patient could have continued treatment for her eating disorder at a lower level of care.  All told, the partial hospitalization program level of care services at issue was not medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  The reviewer is board certified in psychiatry and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. There is sufficient support for the services at issue in this clinical setting. The study by Skaane and colleagues concluded that The use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers. In sum, the services at issue are strongly supported by the medical literature cited above. 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 reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic blood testing for evaluation of her Ehlers-Danlos (EDS) syndrome.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate that the blood genetic testing is medically necessary at this time. While the patients history of hyper-mobile joints, gastrointestinal problems and hernia may indicate that the patient has EDS, before any testing is appropriate, a clinical genetics evaluation to determine the type of EDS is the initial step. There is no submitted record of a clinical genetics evaluation. If the patient is diagnosed with hyper-mobility type of EDS, no testing is available.  On the other hand, if the patient is determined to have an alternative form of EDS, then testing for this type of EDS is available and could be considered.  Based on the patients submitted records, the requested genetic blood testing is not medically necessary in the evaluation of her medical condition at this time. Final Result: The reviewer determined that the requested service is not medically necessary for evaluation of the patients medical condition at this time. Therefore, the Health Plans denial should be upheld at this time.  Credentials/Qualifications:  The reviewer is board certified in clinical 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested epidural steroid injections for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Epidural steroid injections are not medically necessary in this case for the patients chronic back and leg pain.  Although MRI does corroborate radiculopathy, there is lack of documentation that the patient has tried and failed conservative therapy including medications (NSAIDs), physical therapy and a home exercise program. The peer-reviewed literature supports the use of epidural steroid injections in patients who have failed conservative therapy.  There is a lack of support for the services at issue in this clinical setting.  All told, epidural steroid injections were not medically necessary for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C. 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. This applies regardless of fibrosis stage or viral load. Per the guidelines, 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 (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). The patient is ineligible for the alternative for genotype 1a (Viekira Pak with ribavirin) due to a medical condition that can be induced or exacerbated by ribavirin as shown in a trial of ribavirin monotherapy (Dusheiko, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for 12 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 physician 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 reduction mammaplasty for treatment of her medical condition. Findings:  The physician reviewer found that the submitted documentation supports the requested services.  This patient has documented chronic pain of the neck, back, and shoulders. Her examination is consistent with significant macromastia. Conservative management has included NSAIDs, multiple bras, pain injections to the neck and back, as well as physical therapy.  Based on the overall clinical documentation, the patient has failed conservative management over many years.  Her condition of macromastia is causing functional problems and would likely benefit significantly from reduction surgery. This patient has a functional problem that is directly related to her significant macromastia. Breast reduction is a well-known procedure that directly addresses this functional deficit. Thus, the requested reduction mammaplasty is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in 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.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein testing for evaluation of his medical condition.  Findings:  Three physician reviewers found that the submitted records fail to demonstrate the superior effectiveness of the services at issue.  In this circumstance, secondary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees, and are endorsed by several national organizations.   These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein, high sensitivity C-reactive protein, fibrinogen, genetic testing and homocysteine.  Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis.  Randomized trials testing treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits.   Additionally, even though results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results.  Therefore, advanced lipoprotein testing was not likely to have been of greater benefit than other methods of evaluating this patient. Final Result: Three 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 internal medicine with sub-specialty certification in cardiovascular disease 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.