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

Nature of Statutory Criteria/Case Summary: An enrollee has requested Reglan for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Gastroparesis is a common cause of nausea in patients with diabetes.  Reglan is effective for the treatment of diabetic gastroparesis.  It is associated with tardive dyskinesia based on certain trials, although prospective data is lacking.  Camilleri and colleagues noted metoclopramide (Reglan) is the first line of prokinetic therapy and should be administered at the lowest effective dose in a liquid formation to facilitate absorption. The risk of tardive dyskinesia has been estimated to be less than 1%.  This patient has done well with Reglan, and still needs Zofran occasionally for nausea.  Based on clinical literature, the use of Reglan is supported in this case, with well-documented discussion of side effects with the patient.  All told, Reglan 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested an esophageal sphincter augmentation device (LINX) procedure for treatment of his medical condition.  Findings:  Two physician reviewers found that the LINX procedure is not likely to be more effective for this patient than other available treatment options. There is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other surgical anti-reflux procedures. The evidence review by Sheu and Rattner concluded that the long-term safety and efficacy of LINX, both alone and in comparison to current GERD therapies, remains to be determined. The available peer-reviewed literature does not definitively support the conclusion that LINX is more likely to be beneficial than standard treatment such as surgical fundoplication (Sheu, et al). Based on current literature, LINX 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 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 internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition. Findings: Three physician reviewers found that the patient underwent a routine screening mammogram consisting of a combination two dimensional (2D) and three dimensional (3D) tomosynthesis examination.  In addition, she had an automated whole breast sonogram study.  The current images were compared to prior mammograms and no interval changes were noted.  There were no masses, areas of suspicious calcifications, or areas of architectural distortion. However, on the automated whole breast sonogram, benign appearing cysts were noted as well as an indeterminate 5 mm focus in the left breast.  Following the current studies, it was recommended that the patient return for a targeted left breast hand held sonogram.  The patients breast tissues were described as being extremely dense. The Health Plan has denied coverage for the tomosynthesis portion of the exam. The patient is appealing that denial. 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 the dense breast.  Tomosynthesis has not been shown to provide significant increased value in patients who do not have dense tissue that could obscure an abnormality, especially when there have been no changes when compared to prior studies. In this particular patient, the presence of extremely dense breasts is a reasonable indication for tomosynthesis. The ability to separate overlapping breast parenchyma enables delineation of an otherwise occult breast mass. For these reasons, the services at issue were superior to any standard modality available for cancer breast screening.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.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 the enrollees medical condition.  Findings: Two physician reviewers found that there is sufficient support for the services at issue in this patients case.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This new tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers.  For this reason, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with two-dimensional imaging alone.  Final Result: Two reviewers determined that the services at issue 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 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 the LINX procedure for treatment of his gastroesophageal reflux disease (GERD).  Findings:  Two physician reviewers found that overall, there is a lack of randomized controlled trials comparing LINX with Nissen fundoplication or other standard surgical anti-reflux procedures to suggest the LINX procedure would be more beneficial for treatment of this patients GERD than standard therapies. One evidence review concluded that the long-term safety and efficacy of LINX - both alone and in comparison to current GERD therapies - remains to be determined (Sheu and Rattner). Another evidence review concluded that, further studies are required to determine its long-term outcomes and its relative efficacy as compared to other established treatments (Loh, et al). In addition, adverse events, such as erosion through the esophagus, have been reported since U.S. Food and Drug Administration (FDA) approval (Bauer, et al). Moreover, LINX is associated with severe dysphagia requiring endoscopic intervention as compared to surgical fundoplication (Sheu, et al). The American College of Gastroenterology guidelines for the management of reflux disease also state that more evidence is needed before LINX can be recommended (Katz, et al). Based on current literature and clinical guidelines, the requested LINX procedure is not likely to be more beneficial for treatment of this patients medical condition than any available standard therapy. 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 internal medicine with sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested a patent foramen ovale closure for treatment of his medical condition.  Findings:  Two physician reviewers found that the current medical evidence supports the requested services in this clinical setting.  The meta-analysis by Khan and colleagues compared patent foramen ovale closure with medical therapy trials and demonstrated a beneficial effect in the prevention of recurrent neurologic events with percutaneous patent foramen ovale closure.  Additionally, there is potentially significant long-term benefit for avoiding lifelong anticoagulation.  Therefore, the requested patent foramen ovale closure is likely to be more efficacious than other treatment options. Final Result: Two reviewers determined that the requested services are likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are board certified in 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 the ReWalk robotic exoskeleton system for treatment of her spinal cord injury (paraplegia). Findings:  Three physician reviewers found that per the submitted documentation, robotic exoskeleton systems are intended to enable individuals with spinal cord injury at levels T7 to L5 to perform ambulatory functions with supervision of a specially trained companion in accordance with the user assessment and training certification program. In this case, the patient has a history of spinal cord injury with lower thoracic paraplegia. At this level of injury, the patient should be able to perform all essential activities of daily living at a modified independent wheelchair level, consistent with her spinal cord injury. She would be able to use standard or adapted exercise equipment for upper body strengthening and cardiovascular conditioning. She could be expected to be able to stand and ambulate with the use of conventional lower extremity orthoses potentially at a community level which would be included as standard available therapy. Use of a standing frame and regular standing program could be included in an independent home exercise program. In terms of pressure ulcers, performing regular pressure relief while in her wheelchair is the standard of care and an integral part of spinal cord injury education and ongoing management. Lastly, there is a lack of quality studies comparing the requested device against conventional treatments. In sum, the requested ReWalk robotic exoskeleton system is not likely to be more beneficial over other treatment options. Final Result: Three reviewers determined that the requested device 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 physical medicine and rehabilitation 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 residential treatment center (RTC) services for treatment of her behavioral health condition.  Findings: The physician reviewer found that the submitted documentation does not indicate that the patient was at imminent risk of harming herself or others during the period at issue. The patient's symptoms could have been effectively treated in a less intensive setting. She was medically stable and did not evidence need of a 24-hour level of care. Moreover, as detailed above, the records indicate that the patient presented with a chronicity of symptoms throughout her residential stay and was not at imminent risk of relapse or worsening symptoms during this period. In the discharge note it was stated that the patient had not made progress regarding reducing her suicide ideations; however, she was deemed stable for discharge to an outpatient level of care. Based upon these findings, the RTC services were not medically necessary for treatment of the patients behavioral health 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested facial feminization surgery for treatment of her gender dysphoria.  Findings: The physician reviewer found that upon review of the submitted clinical documentation, the medical necessity of the requested services has not been established. The proposed procedures appear consistent with aesthetic improvement, addressing facial aging and appearance concerns rather than specific gender-related abnormalities. The procedures at issue would be considered treatment of relatively normal structures for the patients age. Thus, the requested procedures would be considered cosmetic enhancement. Although facial feminization procedures may be indicated in some transgender individuals, this determination must be made on a case by case basis. In this patients case, she presents with facial features that are consistent with a female appearance. While the proposed procedures may result in aesthetic improvement and create a more youthful appearance, they are not clinically indicated for the treatment of gender dysphoria. Therefore, the requested services are not medically necessary for treatment of the patients medical condition. With regard to the whether the proposed procedures are considered reconstructive in nature, review of the submitted clinical documentation and photographs does not reflect any abnormalities involving the patients brow position, nose, facial structure, lips, facial hair, hairline, forehead and skin. The patients facial appearance is consistent with the appearance of a female. She has signs of aging which are consistent with the normal aging process. With regard to the patients hairline, although she has significant loss of hair anteriorly, this can be present in females as well males. All told, the proposed procedures do not meet reconstructive surgery criteria for treatment of gender dysphoria.Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition or considered reconstructive in nature. Therefore, the Health Plans denial should be upheld.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 tumor treatment fields (TTF) therapy using the Optune system plus transducers for treatment of the enrollees glioblastoma. Findings: Two physician reviewers found that in the medical literature, there is adequate data to support the utility of TTF with the Optune device in this clinical setting. The treatment is a portable medical device that generates low-intensity alternating electric fields. The device has been approved by the U.S. Food and Drug Administration (FDA) for the treatment of glioblastoma. The FDA approval was based on a controlled trial of 237 patients who found that patients treated with TTF had the same overall survival with residual glioblastoma as with chemotherapy, but with a better side effect profile (Stupp, et al). Given this support, the requested TTF therapy using the Optune system plus transducers as 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 equipment is likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.   Credentials/Qualifications: All three physician reviewers are board certified in internal medicine with sub-specialty certification in medical oncology 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested continuation of skilled nursing facility services including physical therapy and occupational therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that spinal cord injury can result in profound functional impairments requiring complex, individualized rehabilitative measures.  In this case, the patient has chronic paraplegia and fell, fracturing his right elbow.  He underwent surgery which was followed by prolonged non-weight-bearing restrictions.  He had been largely dependent for care on account of this most recent injury until his weight-bearing status was liberalized.  After he was allowed weight-bearing as tolerated and aggressive range of motion, he underwent more aggressive therapy and made more progress.  He has been able to propel household distances in a manual wheelchair.  However, he has been requiring minimum assistance for transfers and has largely plateaued at requiring assistance for these transfers.  There is a lack of support for the requested services in this clinical setting.  All told, the requested skilled nursing facility services including physical therapy and occupational therapy 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 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 authorization and coverage for morphine 300 mg per day for treatment of the enrollees retroperitoneal fibrosis.  Findings: The physician reviewer found that the patients records suggest that tolerance has taken place since the start of treatment with narcotics (Chen, et al). Adding more pure mu agonists will only improve the patients symptoms of mu agonist saturation for a short while. However, down regulation will transpire and then the patient would again experience his initial perception of pain. In addition, the patients records do not demonstrate that all non-opioid treatment options have been utilized including behavior therapy (Lee, et al). Consistent with these findings, the requested morphine 300 mg per day is not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition.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.