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

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested 24 hours of psychological testing for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  According to the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameter for Autism, if screening indicates the possibility of autism spectrum disorder, there are various instruments that can be employed for a more thorough assessment.  These include the Autism Diagnostic Interview-Revised, Diagnostic Interview for Social and Communication Disorders and Autism Diagnostic Observation Schedule.  The AACAP recommendation for diagnosis of attention deficit/hyperactivity disorder is a clinical interview with rating scales completed by the parents and the teachers.  These are self-administered scales that require no more than five minutes of professional time to score and evaluate.  Upon reviewing the treating therapists notes, the main concern was the patients problematic usage of language.  If this is the chief concern, a more appropriate referral would have been to a speech/language pathologist for evaluation and further treatment if indicated.  All told, the requested 24 hours of psychological testing is 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 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: 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 there is sufficient support in the peer-reviewed literature for the services at issue in this clinical setting.  Skaane and colleagues performed a large prospective screening trial To assess cancer detection rates, false-positive rates before arbitration, positive predictive values for women recalled after arbitration, and the type of cancers detected with use of digital mammography alone and combined with tomosynthesis.  The authors 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. Thus, the use of breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast exam than conventional mammogram is due to improved cancer detection rate.  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 there is sufficient support for the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to the provider by often allowing the differentiation between dense glandular elements and underlying mass/architectural distortion.  This has resulted in a decrease in callbacks and increase in detection of small cancers, especially in patients with extremely dense tissue.  For these reasons, the addition of breast tomosynthesis to the two-dimensional protocol was likely of greater benefit to the patient than had the examination been done with two-dimensional imaging alone.  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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested breast tomosynthesis for evaluation of her medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the services at issue in this patients case.  Skaane and colleagues reported 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.  Ciatto and colleagues noted that integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls.  Thus, the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate.   Final Result: Two 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 according to the study by Skaane and colleagues, Detection rates, including those for invasive and in situ cancers, were 6.1 per 1000 examinations for mammography alone and 8.0 per 1000 examinations for mammography plus tomosynthesis. Thus, the addition of tomosynthesis allows better characterization of possible masses, spiculation, and architectural distortion. In addition, there is support in the peer-reviewed literature for the use of tomosynthesis in the routine screening population, as this case. Therefore, 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 Foundation One genetic testing for evaluation of her medical condition.  Findings:  Two physician reviewers found that the testing at issue was likely to be more effective for this patient than other available options. The therapy of advanced non-small-cell lung carcinoma (NSCLC) has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas (Pao, et al; Lynch, et al). The mutational landscape of NSCLC has significantly expanded in the past 2-3 years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences (Pao and Girard). It is generally accepted that the panel of mutations typically analyzed in NSCLC are mutually exclusive somatic driver mutations. A study by Von Hoff and colleagues of 86 patients where the progression-free survival on regimen selected by molecular profiling was compared to progression-free survival on the last chemotherapy regimen. The regimen selected by molecular profiling offered a 27% survival advantage (Von Hoff, et al). As such, the use of Foundation One gene testing is considered consistent with current standards of care, and was likely to be 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 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested blood allergy testing for treatment of the enrollees medical condition. Findings:  Three physician reviewers found that the testing at issue is not supported by the peer-reviewed literature. IgG testing for food allergen is not recommended as a diagnostic tool, although IgG is known to play a role in food tolerance (Hofmaier, et al.). While food-specific IgG may be identified more in patients with functional gastrointestinal disorders than in healthy controls, they do not correlate with the presence of abdominal pain (Zuo, et al). In addition, IgE testing is recognized in the evaluation of food allergy, although results must be interpreted by an allergy specialist in the setting of a detailed clinical history (Cox). Therefore, the blood allergy testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy  Final Result: 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: One reviewer is board certified in gastroenterology with sub-specialty certification in pediatric gastroenterology and is actively practicing. Two reviewers are board certified in pediatric gastroenterology 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 Harvoni for eight weeks for treatment of her hepatitis C virus.  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. This applies regardless of fibrosis stage or viral load. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. The guidelines report that patients with diabetes mellitus are at risk for faster progression of fibrosis, and that patients with glomerular filtration rate between 30-60 mL/min do not require dosage adjustment of Harvoni. Patients with viral load of less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, with Harvoni for eight weeks is 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 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 comprehensive breast cancer panel genetic testing for evaluation of her medical condition. Findings: Two reviewers found that the current medical evidence supports the requested services in this patients case.  Multigene panel testing is recommended by the National Comprehensive Cancer Network Guidelines for individuals at risk for genetic mutations. This patient already underwent BRCA1 and BRCA2 testing and was found to be negative.  Given her personal and family history, more complex panel testing would be indicated to determine risk for future cancers.  In sum, the superior efficacy of the requested comprehensive breast cancer panel genetic testing has been established.   Final Result: Two reviewers determined that the requested services are 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested customized acoustic stimulation for treatment of his medical condition.   Findings:  Three physician reviewers found that tinnitus is a mostly subjective phenomenon in the non-vibratory type.  For the patient with this complaint, the symptoms of hearing constant or intermittent noise in one or both ears is difficult to evaluate.  All patients with these symptoms should undergo hearing testing and potential intracranial scanning to differentiate tinnitus that is idiopathic from tinnitus with an observable cause.  The medical literature has not established the superior efficacy of the requested customized acoustic stimulation.  Because of the lack of case controls and long-term benefits, this type of therapy has not been found to offer statistically significant success.  Thus, the requested customized acoustic stimulation is not likely to be of greater benefit than other treatment options.  Final Result: Three reviewers determined that the requested services are 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 otolaryngology 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:  The parent of an enrollee has requested partial hospitalization program (PHP) services for treatment of the enrollees behavioral health conditions.  Findings:  The physician reviewer found that in this clinical setting, the PHP services were medically necessary for treatment of the patients behavioral health condition. While the patient was compliant with her meal plan she continued to struggle and had episodes requiring supervision. The submitted records document concerns from the treating providers about the limited professional support to the parents in a complex family dynamic outside of the PHP program. The provider documented that the patient remained at high risk for relapse. The provider also documented that while depression and anxiety have improved, depression was still prominent and her anxiety still present. Transitioning from partial hospitalization in a setting with limited professional services available and few social supports would have been inadvisable for this patient. As such, the PHP level of care services are medically necessary and appropriate in treatment of this patients behavioral health condition.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested monitored anesthesia services during a colonoscopy for treatment of her medical condition.  Findings:  The physician reviewer found that anesthesia services provided during a colonoscopy were not medically necessary. The patient did not present with a significant history that would require monitored anesthesia care. There is no submitted documentation of co-morbid conditions that would place this patient at risk for complications requiring the need for monitored anesthesia care. Colonoscopy may be safely and effectively performed with conscious sedation of a benzodiazepine alone or with a narcotic in an office-based setting and without the need of monitored anesthesia care with Propofol. McQuaid and colleagues performed a systematic review of randomized controlled trials to compare efficacy, safety, and efficiency of agents used for moderate sedation in esophagogastroduodenoscopy (EGD) or colonoscopy. At the end of the review the authors concluded that moderate sedation [versus deep sedation] provides a high level of physician and patient satisfaction and low risk of serious adverse events with all currently available agents. For the reasons mentioned above, the requested anesthesia services were not medically necessary.  Final Result: The reviewer determined that the service at issue was 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 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 intensity modulated radiation therapy (IMRT) for treatment of her medical condition. Findings:  Three physician reviewers found that there is literature to support the benefit of IMRT in the treatment of gastric cancer.  The study by Ringash and colleagues showed improved target coverage with IMRT versus conventional 3D conformal radiation. In addition, IMRT reduces the dose to the liver and kidneys (Milano, et al; Minn, et al) as well as the heart and spinal cord. In a study by Minn and colleagues, 57 patients treated with IMRT for gastric cancer resulted in improved kidney and liver, and a significantly lower risk of renal toxicity after radiation. In this case, the medical records justify IMRT for this patient to reduce normal tissue dose exposure. As such, the services at issue were likely to be more beneficial for treatment of the patients medical condition than any standard treatments. Final Result: Three reviewers determined that the services at issue were 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: 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:  Two physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis often allows the reader to subtract dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in detection of small cancers.  For these reasons, the addition of breast tomosynthesis to the usual two-dimensional imaging protocol was likely of more benefit to the patient than had the exam been done with two-dimensional imaging alone. Final Result: Two 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.