Persius/hicric huggingface dataset:
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continued coverage for skilled nursing facility services at a post-acute care center for treatment of the enrollees medical condition.  Findings: The physician reviewer found that functional impairments due to acquired brain insults such as stroke can improve with time, but are also amenable to rehabilitation interventions.  The role of inpatient rehabilitative care for persons with significant functional deficits following stroke is relatively well-established in the medical literature.  In this patients case, he had major initial functional deficits following his most recent stroke.  He has been undergoing rehabilitative care at the skilled nursing facility level of care and has made modest progress.  However, his prognosis for functional recovery that will make a significant difference in his assistance needs in the near term is poor, in large part due to his persistent residual dense hemiplegia.  He is anticipated to require significant levels of assistance for most aspects of his care, including his self-care and transfers.  While ongoing rehabilitative services are appropriate and indicated, these services can be provided in a community setting, with custodial level services for his basic self-care.  There are no documented ongoing medical or skilled nursing needs requiring ongoing inpatient care in the submitted records. Therefore, skilled nursing facility services at a post-acute care center forward were not and are not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the services at issue were not and 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 physical medicine and rehabilitation and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuation of transcranial magnetic stimulation (TMS) for treatment of the enrollees major depressive disorder.  Findings: The physician reviewer found that TMS is a non-invasive, neuro-stimulatory intervention endorsed by the American Psychiatric Association (APA) for the treatment of acute phase depression in the adult population. A typical treatment course for TMS is four to six weeks. Avery and colleagues performed an open-label extension study of active TMS in medication-resistant patients with major depressive disorder who did not benefit from an initial course of therapy in a previously reported six-week, randomized controlled study of active versus sham TMS. However, the data used to reach the conclusion was based on an open-label study design. This type of study has the potential for bias since both the patient and the physician know that the active therapy is being provided. This introduces the possibility of an anticipatory expectation that may amplify the placebo effect. At this time, there is a lack of adequately powered, controlled studies showing the benefit of longer courses of TMS therapy. In this case, the patient had no change in two clinical rating scales, and he remained depressed on a third. Further, there was no mention of the specifics of the psychotherapy provided. The most recent medication regimen did not include an antidepressant. Indeed, the combination of lithium and quetiapine is consistent with treatment for bipolar depression which may explain the suboptimal result of TMS thus far as TMS is not approved for bipolarity. In sum, the medical records submitted for review do not support that standard therapies have been exhausted. In addition, the medical evidence does not support a reasonable expectation that continued TMS therapy did or will improve the patients condition or prevent a more serious episode of illness. Accordingly, four unauthorized TMS treatments and 11 more sessions of TMS treatments were not and are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the services at issue were not and 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 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 reimbursement for the contrast-enhanced cardiac computed tomography (CT) angiographies for evaluation of the enrollees hyperlipidemia. Findings:  Two physician reviewers found that the contrast-enhanced cardiac computed tomography (CT) angiography was not supported as likely to be more beneficial than standard risk assessment to determine this patients calcium score. The diagnostic procedure is a screening test that has not been demonstrated to provide improved health outcomes when used on a routine basis. This patient was found to have a score of 826, which placed the patient in a higher risk group. Once the patient was found to have a high calcium score, a stress test was indicated for further evaluation. However, the use of a cardiac CT angiography  was reasonable for further evaluation in lieu of the stress test. The sensitivity and specificity of cardiac CT angiography is similar to other non-invasive tests and obviates the need for a more invasive procedures such as cardiac catheterization. For these reasons, the calcium score was not likely to be more beneficial for evaluation of this patients medical condition than standard testing, but the cardiac CT angiography was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Two reviewers determined that a portion of 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 partially overturned.  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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the peripheral nerve block for treatment of the enrollees left heel pain. Findings:  The physician reviewers found that in the peer-reviewed medical literature, there is a paucity of support for a posterior tibial nerve block prior to a cortisone injection for treatment of plantar fasciitis. The patient was being treated for a diagnosis of plantar fasciitis, with an injection of cortisone. Typically, a local anesthetic is mixed in the same syringe with the corticosteroid, and both are administered together, into the affected area. The patient had been treated appropriately, with conservative modalities, to alleviate her heel pain. After three months, the patient was only 40% improved, and now shows signs of a potential tarsal tunnel syndrome, with a positive Tinels sign. Final Result: Two of three reviewers determined that a portion of the services at issue were and 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 partially overturned. Credentials/Qualifications: Medical professional reviewers number one, two, and three are board certified in podiatry 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the Allergen Specific IgG testing for the evaluation of the enrollees dyspepsia.  Findings:  The physician reviewers found that there is a lack of high-quality peer-reviewed literature supporting the use of IgG food allergy testing for the evaluation of gastrointestinal symptoms. In addition, a number of national and international medical societies have expressed strong recommendations against the use of this testing and concern about its ongoing use for this indication. The American Academy of Allergy, Asthma and Immunology (AAAAI) guidelines state that IgG and IgG subclass antibody tests for food allergy do not have clinical relevance, are not validated, lack sufficient quality control, and should not be performed. The AAAAI guideline for management of adverse reactions to foods states that measurement of specific IgG antibodies to foods is unproven as a diagnostic tool. The European Academy of Allergy and Clinical Immunology reports that as many serum samples show positive IgG4 results without corresponding clinical symptoms, and due to the lack of any controlled studies on the diagnostic value of IgG4 testing in food allergy, such testing does not have value. Given the lack of high-quality trials, and the issuance of broad consensus statements against use of the testing, the Allergen Specific IgG testing  was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: All three reviewers determined that the testing at issue was 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: Physician reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology 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 Harvoni 90-400 mg for treatment of the enrollees hepatitis C. The Health Plan indicated that the requested medication is not medically necessary.  The Health Plan noted that coverage for Zepatier would be provided as an alternative. Findings: The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, 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.  These guideline recommendations are based on multiple randomized clinical trials.  The guidelines also support Zepatier for 12 weeks in this clinical setting.  In genotype 1a patients with negative testing for NS5A resistance-associated variants, Zepatier for 12 weeks is medically appropriate.  The records do not demonstrate a contraindication to Zepatier in this patients case.  Therefore, Harvoni 90-400 mg 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 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 90-400 mg for treatment of the enrollees 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 and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. The guidelines note that all patients should be treated, regardless of fibrosis stage. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. 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.  Therefore, Harvoni 90-400 mg 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 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: 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 medical condition.  Findings: 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.  The current medical evidence supports the services at issue in this patients case.  The presence of lumpiness, especially when it can be localized, is a reasonable indication for breast tomosynthesis.  Also, the extremely dense nature of her breasts is an appropriate indication for evaluation with breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, bilateral breast tomosynthesis was 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested laser therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting. This patient has tried and failed therapy with topical ketoconazole cream. There is no medical documentation of the patient having tried and failed or demonstrating a contraindication to treatment with oral antifungal agents, such as terbinafine.  Terbinafine is considered to be a first-line agent in the treatment of onychomycosis.  Use of laser treatments for onychomycosis continues to be evaluated, but is not considered to be standard of care.  Per the submitted documentation, the patient had not tried and failed standard oral therapies.  Thus, laser therapy was not likely to have been more effective than other treatment alternatives.Final Result: Three reviewers determined that 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 dermatology 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: The parent of an enrollee has requested authorization and coverage for general anesthesia for treatment of the enrollees dental condition.Findings:  The physician reviewer found that general anesthesia for pediatric dental procedures is generally considered to be a safe and effective practice.  General anesthesia is often employed to facilitate extensive dental treatment, particularly in younger pediatric patients who do not have the psychological or emotional maturity required to cooperate in an office setting.  The combination of an inability to cooperate and a need for an extensive dental procedure makes general anesthesia an appropriate treatment modality for some pediatric patients.  Because dental restoration under general anesthesia does not require cooperation from the child, it is a very efficient treatment modality.  It can usually be completed in one procedure.  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 anesthesiology with sub-specialty certification in pediatric anesthesiology 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 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 particular patient, she has breasts that have been described as being very dense. 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: All 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An male enrollee has requested reimbursement for the genotype DNA/RNA hepatitis C virus testing (CPT 87902) for evaluation of the enrollees pneumonia and chronic hepatitis C virus.  Findings:  The physician reviewers found that In 2012, the Centers for Disease Control and Prevention (CDC) expanded its guidelines originally issued for risk-based hepatitis C virus testing with a recommendation to offer a one-time hepatitis C virus test to all patients born from 1945 through 1965. This recommendation was supported by evidence demonstrating that a risk-based strategy alone failed to identify more than 50% of hepatitis C virus infections in part due to patient underreporting of their risk and provider limitations in ascertaining risk-factor information. Once hepatitis C virus is identified in an individual patient, the American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) guidelines strongly recommend testing based on CDC recommended testing algorithm. Testing should include quantitative hepatitis C virus RNA testing prior to the initiation of antiviral therapy to document the baseline level of viremia, and genotyping to guide selection of the most appropriate antiviral regimen. Final Result: All three reviewers determined that the testing 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 reviewers number one, two, and three are board certified in internal medicine with sub-specialty certification in gastroenterology 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.