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 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.  It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  Similarly, the areas of asymmetry are appropriately evaluated with breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  Thus, breast tomosynthesis performed was likely to have been superior over other methods of evaluation. 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: 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 the patient has a history of prior biopsy and the presence of extremely dense breast tissue. 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. In addition, the area of asymmetry is a further indication for tomosynthesis. Therefore, breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Avastin in combination with chemotherapy for treatment of her medical condition. Findings: Two physician reviewers found that Avastin has been approved for use, along with chemotherapy, in several types of cancer. It has demonstrated some activity in uterine cancer.  Lorusso and colleagues compared results in patients who had had prior treatment, with chemotherapy alone or chemotherapy with Avastin.  The combination did demonstrate a higher response rate and progression free survival, but no significant difference in overall survival. At this time, there is a lack of convincing data as to the clinical benefit from adding Avastin to chemotherapy in this clinical setting.  All told, Avastin in combination with chemotherapy is not likely to be of greater benefit than other treatment options in this patients case.  Final Result: Two reviewers determined that the requested medication is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical 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: An enrollee has requested Norco for treatment of his medical condition. Findings: The physician reviewer found that the submitted records fail to demonstrate the medical necessity of the requested medication.  Per the medical records, non-opioid treatment options have not been exhausted.  The records do not document behaviorial therapy, despite much research to support its use.  In this patients case, non-opioid medications have been optimized.  There is a lack of support for the requested medication in this clinical setting.  All told, 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Otezla for treatment of her medical condition. Findings: The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication.  This patient was previously treated with methotrexate, which she did not tolerate, and prednisone.  Her current treatments include multiple topical steroids, topical Vitamin D analogues and a topical retinoid cream.  The Health Plan has required a trial and failure or contraindication to the use of two formulary preferred biologic medications.  This requirement is medically appropriate.  Given that there are no documented adverse reactions or contraindications to biologic therapy, Otezla 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 dermatology 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 the prostatic urethral lift procedure (Urolift) for treatment of his medical condition. Findings: Two reviewers found that the review of the relevant peer-reviewed literature reveals a lack of support for the requested procedure in this patients case. While Urolift has shown initial safety and efficacy in the treatment of benign prostatic hyperplasia (BPH) symptoms, long term efficacy data is lacking to compare  the procedure to currently available ablative procedures such as laser photo selective vaporization of the prostate (PVP). Further research may reveal equivalence but study-controlled results are still pending. In the absence of long term data documenting the superior efficacy of the Urolift procedure, the requested procedure is not likely to be more beneficial for treatment of the patients BPH than standard treatment modalities.  Final Result: Two reviewers determined that the requested procedure is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications:  All three reviewers are board certified in urology 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 partial hospitalization program (PHP) level of care for treatment of her behavioral health condition. Findings: The physician reviewer found that the medical records indicate that the patient did not receive an adequate amount of supervision and support when she was stepped down from PHP to IOP.  Her coping skills were not sufficiently developed for her to deal with the stressors she encounters on a daily basis.  There are clear signals that she has been relapsing and requires treatment at the present level of care.  The treatment teams decision to increase the intensity of services and transfer the patient back to PHP level of care was medically appropriate and indicated in light of her prior response to treatment at that setting. Continued treatment at the PHP level is warranted given the patients ongoing symptomatology. Based on the submitted documentation, PHP level of care is reasonable and medically necessary for treatment of this patients behavioral health condition.Final Result: The reviewer determined that the services at issue were and 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested residential treatment center services for treatment of her behavioral health conditions. Findings: The physician reviewer found that the submitted documentation supports the services at issue in this clinical setting. The patient had a concerning history which dominated multiple functional domains. The patient had been unable to achieve any meaningful sustained sobriety in an extended period of time. Further, the patient had significant psychiatric comorbidity in the presence of acute psychosocial stressors. Based on the medical records, discharge to a less restrictive setting would have been premature and resulted in undue morbidity, prompt relapse and re-admission. The patient was noted to be gaining insight and motivation for improvement, but still struggling with dysphoria, self-defeating behavioral urges and negative self-talk. The records demonstrate that the patient had not consolidated the treatment gains necessary to success in a less restrictive setting. The services provided during the timeframe at issue were for active treatment, and reasonably expected to improve her condition and prevent a more serious episode of illness. All told, residential treatment services were medically indicated for the treatment of this patient. Final Result: The reviewer determined that the services at issue were 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested suction assisted lipectomy of the trunk for the treatment of her medical condition.  Findings:  The physician reviewer found that the services at issue were medically indicated for the treatment of this patient.  Based on this patients evaluation and review of the photographs, the appearance of the axillae is related to her treatment of breast cancer.  The patients condition constitutes an abnormal structure of the body.  This abnormal structure of the body was a direct result of her treatment for breast cancer.  The surgery was performed to create a normal appearance to the extent possible.  The level of abnormality was significant and the planned procedure was in an attempt to approximate a more normal appearance.  The liposuction would likely to have offered more than a minimal improvement in the patients appearance.  In sum, suction assisted lipectomy of the trunk was medically necessary and was reconstructive in nature.  Final Result: The reviewer determined that the services at issue were reconstructive in nature and were 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested three-dimensional (3D) breast tomosynthesis for evaluation of her medical condition.  Findings:  Three physician reviewers found that the patient has a strong history of breast cancer, and also has a personal history of melanoma. Considering all factors including her age, medical history, personal history of malignancy, and strong family history of breast cancer, tomosynthesis is a reasonable tool for this particular patient. All told, 3D breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the 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 substance abuse residential treatment services for the treatment of his behavioral health conditions.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  Per the medical records, the patient was doing well in cognitive behavioral therapy and 12-step and the daily clinical record revealed that the patient was motivated for care, making good progress and had no new stressors.  He denied suicidal ideation and there was no evidence of behavioral dysregulation, an acute psychiatric syndrome or unresolved medical condition.  The record did not include an inventory of past treatment interventions such as community- or school-based services, family therapy, intensive outpatient programming or partial hospitalization with a supportive living environment.  Thus, the records do not demonstrate transition to a less restrictive setting would have been inadequate or unreasonable.  Considering the clinical presentation and patient history, substance abuse residential treatment services 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 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 home health physical therapy for the treatment of his medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Per present evidence-based clinical practice guidelines for the management of chronic low back pain, the focus of treatment should be patient education, self-care, common analgesics, exercise and remaining active.  Formal physical therapy may be needed in some cases for instituting an appropriate exercise and independent modality program, but there is no necessity for a home based therapy program if a patient is able to attend an outpatient program.  The records in this case do not establish that the patient would be unable to perform an independent program or travel to outpatient therapy.  The records indicated normal lower strength, capacity to drive more than 1.5 hours, and capacity to walk at least half a mile.  Despite his ongoing symptoms, services such as formal therapeutic exercises, formal modalities and manual therapy in the setting of chronic low back pain, moreover, provide no proven marginal benefit on health or functional outcomes over independent exercise and self-administered palliative interventions such as massage using rollers, or passive palliative modalities such as local ice/heat.  All told, the requested home health physical therapy is not medically necessary 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 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 Synvisc One injections for the treatment of his medical condition. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  Based upon a review of the recent literature, evidence-based guidelines no longer support viscosupplementation for osteoarthritis of the knees.  Jevsevar and colleagues performed a study of viscosupplementation for osteoarthritis of the knee.  The meta-analysis of the double blinded, sham-controlled trials with at least 60 patients did not show clinically important differences of hyaluronic acid treatment over placebo.  When all literature was added to the analysis, the overall effect was greater but was biased towards stronger treatment effects because of the influence of non-blinded or improperly blinded trials.  There is a lack of support for the requested services in this clinical setting.  All told, the requested Synvisc One injections are 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 orthopedic 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for the treatment of his 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.  This applies regardless of fibrosis stage or viral load.  Per the guidelines, treatment-naive, non-cirrhotic, genotype 1a patients should be treated with Harvoni for eight to twelve weeks, or with Viekira Pak and ribavirin for twelve weeks. These guideline recommendations are based on multiple randomized clinical trials.  Although treatment is needed in this case, no medical rationale supported by current literature is provided to support the use of Harvoni over Viekira Pak in this patients case.  For these reasons, the requested treatment with Harvoni 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 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.