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. Tomosynthesis is a valuable tool in evaluating areas of asymmetry. The ability to discern whether an area of asymmetry represents an occult mass as opposed to summation of overlapping tissue is often clarified with these cross-sectional images. As such, breast tomosynthesis was likely to be more beneficial for evaluation of the patients breast tissue than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of your 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Harvoni for treatment of his hepatitis C virus (HCV). 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. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C genotype 1 regardless of fibrosis stage (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, Harvoni is medically necessary for treatment of the patients HCV.   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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested chiropractic services for treatment of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  This patient was being treated for generalized back, neck, and head pain. The records show no objective, measurable, and functional gains in daily living or reduction of medication. There was no documentation submitted regarding basic history or examination findings and no long-term or short-term treatment goals. Evidenced-based guidelines generally recommend a trial of therapy for chronic pain. However, the provider has failed to provide a sufficient history or examination to document the patients condition or history of chronic pain.  All told, chiropractic services were not medically indicated 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 chiropractic care 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 treatment of his hepatitis C virus (HCV).  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 (AASSLD/IDSA), all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions. While eradication of the patients HCV is medically appropriate, AASSLD/IDSA guidelines recommend Viekira Pak over the Harvoni regimen in treatment of patients who have HCV, genotype 4 and are treatment-naive. No medical rationale supported by current literature is provided to support the use of Harvoni over Viekira Pak.  All told, the medical necessity of the requested Harvoni has not been established.   Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested the Afirma Gene Expression Classifier test for evaluation of her medical condition.   Findings:  Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma test utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  In sum, Afirma Gene Expression Classifier testing was likely to have been superior over 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 internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism 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 sinus endoscopy for treatment of her obstructive sleep apnea.  Findings:  Three physician reviewers found that while it is possible that nasal/sinus endoscopy was done in further evaluation of this patient's past and chronic sinus problems, it is not stated as such in the records provided. Recent medical literature regarding in office nasal/sinus endoscopy revolves mainly around its use in endonasal sinus surgery (ESS). Per a position statement of the American Rhinologic Society, indications for nasal endoscopy include evaluate for chronic sinonasal symptoms unexplained by anterior rhinoscopy, assessment of interval response to medical or surgical therapy of sinusitis, monitor for recurrence of polyps, evaluate and manage epistaxis, perform endoscopically guided cultures, assess facial pain suggestive of rhinogenic origin, evaluate clear rhinorrhea suggestive of cerebrospinal fluid leak, perform initial diagnosis and interval surveillance for sinonasal neoplasms. There is no documentation of any of these elements in the patient's records and thus no indication that this procedure was appropriate in this setting. As such, the service at issue was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the service at issue was 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:  An enrollee has requested a second afternoon dose of Adderall, in addition to her morning dose of Adderall for treatment of her behavioral health condition.  Findings:  The physician reviewer found that prescribing a second, mid-day stimulant dose is common practice in clinical ADHD management. This practice is consistent with contemporary practice standards.  It is the outcome of rationale prescribing adhering to patient-centric principles, which appears to be the case in this particular dispute.  As above, stimulant medication is the first-line treatment for ADHD.  Thus, the medication is reasonably expected to improve the patients ADHD. The overall dosing of the medication is within recommended guidelines and there does not appear to be any relative contraindication to the split-dosing. As such, the requested Adderall XR every morning and every afternoon is medically necessary for treatment of the patients medical condition. Final Result: The reviewer determined that the requested medication dosage 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested partial hospitalization program services (PHP) for treatment of her behavioral health condition. Findings: The physician reviewer found that per the American Psychiatric Association (APA) guidelines, there are various services available for the treatment of eating disorders: intensive inpatient settings, in which sub-specialty general medical consultation is readily available; residential and partial hospitalization programs; and outpatient care, in which the patient can receive general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy. Pre-treatment evaluation of the patient is essential for determining the appropriate treatment setting. Patient weight, rate of weight loss, cardiac function, and metabolic status are some of the most important physical parameters that providers look at when making a determination as to treatment options for their patients. In this patients case, there was no clinical indication for the PHP.  Review of the patients medical records demonstrates that a lower level care, such as an intensive outpatient program, would have been a medically appropriate and safe treatment option for the patient. Therefore, the partial hospitalization program (PHP) 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 behavioral health 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 computed tomography (CT) of the cervical spine for evaluation of his neck pain and other radicular symptoms in the upper extremities. Findings: The physician reviewer found that this patient is at risk for significant cervical spine pathology based upon the mechanism of injury; however, the submitted record does not indicate that a CT scan is medically necessary in this clinical setting. While there is a reference in the providers letter that conservative therapy had been tried, there is no record to show that conservative therapy had been initiated; there is only a reference to an x-ray showing degenerative changes but no formal report is included in the records provided. Also, not present in the records is documentation to indicate that a spinal stimulator or other contraindication to an MRI of the cervical spine is present in this case. The patient's surgery was performed several months ago and there should be no artifact created by hardware in the lumbar spine, an area well out of the field of view. It would be unusual, being post-op for several months, that the patient would have any contraindication due to the prior procedure unless there is something about the hardware making it ferromagnetically incompatible; a situation very unusual in current practice. In sum, cross sectional imaging may be necessary following a trial of conservative management or if there is neurological deterioration in the interim. For these reasons, the requested CT scan is not medically necessary for evaluation of this patients neck pain and other radicular symptoms in the upper extremities.Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in radiology 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 Xyrem for treatment of her medical condition. Findings: The reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested medication in this patients case.  The use of Xyrem in the treatment of narcolepsy is well-documented with current medical literature.  The patient has previously failed a trial of a central nervous system stimulant.  However, the records document concurrent prescriptions of multiple sedative agents which were prescribed by the patients non-sleep physician.  The use of benzodiazepines and other sedative agents is an explicit contraindication to the use of Xyrem.  In this case, there is no formal indication that the use of the sedative agents will be discontinued outside of a letter requested by the patient for submission to the insurance company.  In the primary interests of patient safety, given the history of benzodiazepine use and active prescriptions for such drugs, the request for authorization cannot be recommended for approval at this time.  The risk of an adverse outcome with the drug combination is too great.  All told, Xyrem 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 neurology with sub-specialty certification in sleep 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested 12 weeks of Harvoni for treatment of his hepatitis C virus.  Findings: The physician reviewer found that according to the most recent 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. According to the guidelines, patient with HIV co-infection and cirrhosis are considered high priority for treatment. The guidelines recommend that treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks. These guideline recommendations are based on multiple randomized clinical trials, and the medication is U.S. Food and Drug Administration (FDA)-approved for all patients with chronic hepatitis C, genotype 1 regardless of fibrosis stage. For these reasons, the requested treatment with Harvoni for 12 weeks is supported as medically necessary for 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested excision skin infraumbilical panniculectomy for treatment of her medical condition. Findings: The physician reviewer found that there is sufficient support for the requested services in this clinical setting.  There is evidence of a symptomatic lower abdominal pannus in association with abdominal hernias.  Her symptoms include abdominal pain treated conservatively with narcotic analgesia and chronic rashes/irritation treated topically.  Her examination and photographs are supportive of a large overlapping abdominal pannus, contributing to her functional deficits of pain and chronic irritation/infection.  This has been documented to affect her activities of daily living.  This is supported by documentation from her treating providers.  In this patients case, the panniculectomy can provide adequate exposure for the repair of multiple hernias and allow for resolution of her functional complaints of pain and chronic, recurring rashes.  The weight and size of her pannus is directly affecting her activities of daily living with mobility, resulting in chronic pain and recurring irritation.  Panniculectomy would likely directly address these deficits.  All told, the requested excision skin infraumbilical panniculectomy is medically indicated for the treatment of this patient.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 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested inpatient psychiatric hospitalization for treatment of her behavioral health conditions.  Findings:  The physician reviewer found that the denial of inpatient psychiatric hospitalization should be partially overturned. Inpatient care was medically necessary initially; however, the clinical record does not support the subsequent medical necessity for service delivery at the inpatient level of care.  Initially, the patient was emotionally labile and hearing nonspecific things. While the patient remained symptomatic from the episode that prompted the admission, the acute psychiatric syndrome was waning and there were several reassuring factors, such as the chronicity of the longitudinal illness burden, the denial of any suicidal ideation, and the patients well-organized thinking and ability to track well during conversation, despite reports of auditory hallucinations. In the absence of any additional clinical documentation evidencing active treatment that was reasonably expected to improve the patients condition or prevent a more serious episode of illness, the clinical situation improved to the point where transition to a less restrictive setting would have been appropriate.  Thus, initial services at the acute inpatient level of care were medically necessary but not thereafter.  Final Result: The reviewer determined that inpatient psychiatric hospitalization was medically necessary initially for treatment of the patients behavioral health condition, but not thereafter. Therefore, the Health Plans denial should be partially 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.