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 was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, a mass found in the right breast was a new or changing development since the prior studies. In this circumstance, tomosynthesis is indicated to better distinguish the mass in terms of its contours and margins. This is especially true when the mass is only detected on one view. For the reasons provided, the services at issue were 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: 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 tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Specifically, those patients who have dense breasts can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Given this support, 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 Zepatier and ribavirin for treatment of his hepatitis C.  Findings: The physician reviewer found that according to the joint guidelines issued by the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. Per guidelines, genotype 1 patients who have failed Sovaldi and ribavirin therapy should be treated with Harvoni and ribavirin for 12 weeks. These guideline recommendations are based on multiple studies showing the effectiveness of treatment with Harvoni after treatment failure with Sovaldi (Osinusi, et al; Reddy, et al). The guidelines state that there are no published data on retreatment of sofosbuvir-containing treatment failures with non-sofosbuvir based [direct-acting antiviral] DAA regimen. Guidelines further state that given the lack of available data recommendations cannot be made. For these reasons, the requested treatment with Zepatier and ribavirin has not been established as medically necessary for the treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested medications are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program (PHP) services for treatment of her behavioral health condition. Findings: The physician reviewer found that based on the documentation submitted for review, the PHP services were not medically necessary for treatment of the patients behavioral health conditions. The medical records submitted for review do not demonstrate that the patient met criteria for treatment at the PHP level of care. The patient was extremely well motivated, compliant in treatment and was relatively self-sufficient. The level of motivation and compliance in patients is the main criterion that distinguishes the need for PHP versus intensive outpatient program (IOP) level of care. Both levels require that the patient be medically stable and not at risk of harm to self or others. In IOP, the patient would still have had access to individual therapy, group and nutritional counseling, but fewer hours per day. There is a lack of evidence in the medical records submitted demonstrating that the patient would have relapsed and needed re-hospitalization if she had been transitioned to a lower level of care. Given the above, the services at issue have not been established as medically necessary for treatment of the patients medical condition.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Orthovisc injections in both knees for treatment of her medical condition.  Findings: The physician reviewer found that there is sufficient support in the peer-reviewed literature for the requested services in this clinical setting. Pagnano and Westrich conducted a systematic review on the efficacy and safety of repeat courses of hyaluronan therapy in patients with osteoarthritis of the knee and concluded that repeat courses of the hyaluronans were safe and effective in the treatment of pain associated with osteoarthritis of the knee. In addition, Turajane and colleagues concluded that repeated cycles of intra-articular sodium hyaluronate treatment to delay time to total knee replacement in patients with knee osteoarthritis after failing conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has a diagnosis of bilateral knee osteoarthritis. She has undergone prior viscosupplementation series with reported relief with the most recent injection series. She has failed to respond to other conservative treatment including anti-inflammatory medications, activity modification, and previous corticosteroid injections. Therefore, the requested Orthovisc injections in both knees has been established as 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested a Life Vest wearable defibrillator for treatment of her medical condition. Findings: Two reviewers found that the superior efficacy of the wearable device at issue has been met in this patients case.  Due to a sustained ventricular arrhythmia requiring defibrillation and a dilated cardiomyopathy with low ejection fraction the wearable cardioverter defibrillator (WCD) was more likely to reduce this patients risk from sudden cardiac death (SCD).  In patients who are at high risk of SCD while undergoing a trial of optimal medical therapy, the WCD provides protection against SCD while awaiting improvement in left ventricular function, ICD implantation, or if needed, cardiac transplantation. In the largest post-marketing study of the WCD, 0.7 percent of patients prescribed a WCD for recently diagnosed non-ischemic cardiomyopathy required shocks for a ventricular tachyarrhythmia over a mean follow-up period of 57 days (Ching, et al). Although this event rate was relatively low, for selected patients with severe but potentially reversible cardiomyopathy, such as tachycardia or myocarditis, associated cardiomyopathy, the WCD may be useful for the prevention of SCD due to ventricular arrhythmias. For all these reasons, the WCD provided to the patient, was likely to be more beneficial for treatment of her medical condition than any available standard therapy.  Final Result: Two reviewers determined that the device at issue was 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 physician reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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 lipoprotein testing for evaluation of his medical condition. Findings: Three physician reviewers found that prevention guidelines for the routine use of advanced lipoprotein tests in the management of cardiac risk are limited, mainly because it is unclear how much incremental prognostic information is provided by these tests beyond that available from a standard lipid panel. In this particular patient, previous fasting lipid studies necessitated initiation of a specific medication therapy and addition of generic medication to treat elevated cholesterol. Given the presence of known baseline coronary risk factors including hypertension, hyperlipidemia, obesity, and metabolic syndrome, this patient is already at high risk for a cardiovascular event. In this clinical setting, there was no additional diagnostic or prognostic information to be gleaned by testing for risk factors with an advanced lipoprotein test. As such, the advanced lipoprotein testing performed was not likely to have been more helpful for evaluation of this patients medical condition than other standard alternatives. Final Result: Three reviewers determined that the service 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: All three physician reviewers are board certified in internal medicine with sub-certification in cardiovascular disease 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 an intraoral device for treatment of his obstructive sleep apnea (OSA).   Findings:  The physician reviewer found that the records in this case indicate that the patient carries a diagnosis of OSA. The records do not indicate any significant medical changes that would contribute to the amelioration or resolution of sleep disordered breathing such as surgical intervention or significant weight loss. In addition, the records indicate the patients body mass index (BMI) is not reflective of obesity. Current practice guidelines form the American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) support the use of oral appliance therapy in patients with mild or moderate OSA who are intolerant of or decline CPAP (Ramar, et al). As a result, the provision of an oral appliance in this case would be within the currently accepted standards of medical practice for the treatment of OSA. Accordingly, the intraoral device provided to this patient for the treatment of OSA is supported as medically necessary.  Final Result:  The reviewer determined that the device at issue was 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 sleep medicine and neurology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Embeda for treatment of her medical condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the medical necessity for Embeda has been established in this clinical setting. Embeda has been noted to provide adequate analgesia without side effects and is comparable to Avinza. In addition, the patient is at low risk for opioid abuse, and she has tried and failed other morphine alternatives. Since Avinza was discontinued, she has tried and failed Kadian and two other MS Contin formulations. In addition, she has tried and failed fentanyl patch, Opana and Oxycodone.  Embeda is a long acting morphine agent which has provided the patient with adequate pain relief. Given that she has exhausted other morphine formulations, Embeda was and is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the medication at issue was 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 anesthesiology with sub-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 ambulance transport services on an emergent or urgent basis.  Findings:  The physician reviewer found that review of the submitted clinical documentation demonstrates that a prudent layperson would not have sought ambulance transport on the date in question. In this case, emergency medical services were dispatched due to intermittent abdominal pain. His vital signs were normal. He was in mild distress. He was able to ambulate with assistance to the ambulance stretcher. There is no documentation that the patient suffered from a condition that risked placing the patients health in serious jeopardy, causing serious impairment to bodily functions, or serious dysfunction of any bodily organ or part. All told, the services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the date in question. In this case, the patient presented with intermittent abdominal pain and constipation with no nausea or vomiting. His vital signs were normal and his level of distress was mild. The documentation submitted for review fails to demonstrate signs or symptoms of infection or injury that would require immediate treatment. There is no documentation to suggest a prudent layperson would believe that the absence of immediate medical attention would result in serious impairment to bodily function. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed immediate medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation on the date in question, the patient did not meet prudent layperson criteria for urgently needed services. As such, the Health Plans denial should be upheld.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in emergency 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 residential treatment center (RTC) services for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that the records provided for review indicate that this patient no longer met standard criteria for RTC level of care. The notes indicate that she was very compliant with treatment and was developing insight as well as coping skills to deal with her issues. She was not overtly experiencing any hallucinations and was not a risk of harm to herself or others. Her medications were adjusted and stable and she was participating in family therapy. Thus, her treatment could have been continued safely in a less structured setting. For these reasons, the RTC services at issue were not and are not medically necessary for treatment of this patients medical condition. 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 with sub-specialty certification in child and adolescent 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Odomzo (sonidegib) for treatment of his medical condition. Findings:  Two physician reviewers found that Odomzo is not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. In this case, the patient has received prior treatment with the sonic hedgehog inhibitor Erivedge (vismodegib). According to the National Comprehensive Cancer Network (NCCN) guidelines, results from phase I-II trials with small BCC sample sizes (N < 40 patients) have shown that itraconazole and saridegib can elicit responses in patients with BCC, although not in patients who previously received vismodegib (n = 12 patients tested). Thus, treatment with Odomzo (sonidegib) is not likely to have a response since it also shares the same hedgehog pathway as vismodegib. Therefore, treatment with Odomzo is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. 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 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital 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. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Thus, digital breast was likely to have been more efficacious 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 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.