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

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested behavioral analysis (ABA) therapy for treatment of the enrollees medical condition.  Findings: Two physician reviewers found that the submitted documentation establishes the medical necessity of the services at issue. Reichow and colleagues reviewed the evidence for the effectiveness of early intensive behavioral intervention (EIBI) in increasing the functional behaviors and skills of children with autism. The authors reported improvements in cognitive skills, adaptive skills and communication with this type of treatment. Mohammadzaheri and colleagues noted that ABA is helpful for school children with autism spectrum disorders for aggressive, disruptive and tantrum behaviors. In this case, the patient has been making progress. There is a lack of evidence that this patient has maximized progress. Thus, ABA services at the frequency of 40 hours per week of ABA therapy and supervision is medically necessary for treatment of the patients maladaptive behaviors.  Final Result: Two reviewers determined that the services at issue were and are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: Physician reviewer number one is actively practicing and is board certified in pediatrics and child neurology. Physician reviewer number two is actively practicing and is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics. Physician reviewer number three is actively practicing and is board certified in child neurology.  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 the Afirma gene test for evaluation of her medical condition.  Findings: Three physician reviewers found that the patients biopsy showed a follicular thyroid lesion of undetermined significance. The requested Afirma gene test in similar clinical situations is an accepted standard for further evaluation. Moreover, the Afirma test is consistent with the recommendations from the National Comprehensive Cancer Network (NCCN) to help determine the malignant potential. For these reasons, the requested Afirma gene test is likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the requested testing is 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 internal medicine with sub-specialty certification in oncology and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni for treatment of her hepatitis C virus. Findings: The physician reviewer found that in the past, treatment for patients with early stage hepatitis C virus was delayed in order to wait for more effective, less toxic treatment. This has now changed with the introduction of Harvoni, which is a once daily pill that is used without ribavirin and has no serious adverse effects or contraindications. The U. S. Food and Drug Administration label is clear regarding Harvonis approved use, which includes early stage disease. This is exactly the case for this patient who should be treated even though she does not present with advanced liver disease. Moreover, the position of American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommends that all patients with chronic hepatitis be treated except those with limited life expectancy of 12 months or less due to a non-liver related condition. Therefore, the requested Harvoni is medically necessary for 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: 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 breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three-dimensional (3D) digital breast tomosynthesis (DBT) reduces false positives and increases cancer detection when compared to two-dimensional full field digital mammography (FFDM, 2D) alone. Recall rates are reduced by 15-17%: 3D allows for separation of structures to differentiate architectural distortion from masses and overlapping fibroglandular tissue (asymmetries). Studies have also shown that there has been an increase in cancer detection by 33-53%: cancer detection increased from 6 cancers/1000 women screened with 2D to 8 cancers/1000 women screened with 3D. Three-dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening.  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 physician 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 or in the alternative, Zepatier, for treatment of her 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. The guidelines recommend that treatment-naive genotype 1b patients should be treated with Harvoni or Zepatier. These guideline recommendations are based on high-quality clinical trials for Harvoni and for Zepatier (Kowdley, et al; Afdhal, et al).  Harvoni was recommended by the patients provider as the preferred direct direct-acting antiviral for this patient. The proposed use of Harvoni is medically appropriate and consistent with AASLD/IDSA guidelines. For these reasons, treatment of hepatitis C with Harvoni is supported as medically necessary for treatment of this patients hepatitis C infection.  Final Result: The reviewer determined that the requested Harvoni 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 breast tomosynthesis for evaluation of her medical condition.  Findings: Two physician reviewers found that breast tomosynthesis provides advantages to radiologists interpreting mammograms.  Often this addition of breast tomosynthesis to two-dimensional mammography allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in biopsies, decrease in callbacks and increase in detection of small cancers.  Thus, the addition of tomosynthesis to the usual two-dimensional imaging 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 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.  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 several years ago as a problem solving adjunct to routine mammography. Applying the same basic concept as computed tomography (CT) scanning, by separating the various layers of breast tissue, one can better detect abnormalities. In this particular patient, tomosynthesis was valuable. While the overall breast density was average, there was an area of focal increased density that explained a palpable abnormality. The breast sonogram was also indicated, as there were additional findings on the mammogram. Thus, in this clinical setting, the use of the digital 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 physician 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 a Synvisc One injection for treatment of her medical condition.  Findings: The physician reviewer found that the review of the submitted documentation and relevant literature demonstrates the medical necessity for the requested services. The evidence based literature supports the use of repeat series of viscosupplementation injections for the treatment of pain in patients with osteoarthritis of the knee. The study by 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 which failed conservative treatment was found efficacious during a 54-month follow-up period. In this case, the patient has been diagnosed with right knee osteoarthritis. She has been treated with prior viscosupplementation injections with good pain reduction, followed by gradual return of symptoms. She has also failed to respond to other conservative treatment. Therefore, the requested Synvisc One injection for the right knee is 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 physician reviewer is board certified in orthopedic surgery and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: 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 while this patients record may not support advanced fibrosis, current American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations support the medical necessity and medical appropriateness of HCV treatment. Also per the guidelines, 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. In addition, Harvoni carries the highest AASLD/IDSA recommendation (Rating: Class I, Level A) for treatment of HCV patients with the patients characteristics. `Once-daily ledipasvir-sofosbuvir with or without ribavirin for 12 or 24 weeks was highly effective in previously untreated patients with HCV genotype 1 infection. (Afdhal, et al; Gentile and Borgia). In sum, Harvoni is medically necessary for treatment of the 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.Qualifications/Credentials:  The physician 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 excision of benign skin lesion with reconstruction of left lower lid procedure for treatment of her medical condition. Findings: The physician reviewer found that the excision of benign skin lesion with reconstruction of left lower lid procedure was not medically necessary for treatment of the patients medical condition. The medical records submitted for review fail to document a medical and functional indication for eyelid surgery. The clinical note states lid redundant fold as the indication for surgery. However, this descriptor does not refer to a pathologic process. All told, the excision of benign skin lesion with reconstruction of left lower lid procedure was not 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 ophthalmology with sub-specialty certification in ocuplastic 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 bilateral mastectomy with male chest reconstruction for treatment of his gender dysphoria.  Findings: The physician reviewer found that the surgical concept of bilateral mastectomy for purposes of female-to-male gender reassignment is well established and documented within the community of plastic surgeons. Each patient must be reviewed on a case-by-case basis to determine medical necessity. In this patients case, medical necessity has been adequately established based upon the medical documentation provided. The patient has identified as a male for a significant amount of time and is under the care of a therapist, who is supportive of the treatment plan. This patient is noted to have significant female breast development. Thus, based on the entirety of the record the patient meets medical necessity criteria for bilateral mastectomy with male chest reconstruction.  The proposed procedure also meets criteria for reconstructive surgery in this case. His female breast development would be considered an abnormal male structure. The abnormal appearance is the result of the patients gender dysphoria and any appropriate surgical correction would attempt to obtain a more normal male appearance. Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition and are reconstructive in nature. 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 abdominoplasty for treatment of her medical condition.  Findings:  The physician reviewer found that the patient has significant abdominal pain secondary to severe rectus diastasis.  This is a significant abnormal condition of severe loss of abdominal competence.  This condition is related to her previous pregnancy, which has caused her significant abnormal abdominal wall incompetence.  Although it is not clear that her functional deficit would likely be improved, the appearance is severely abnormal and her planned treatment would attempt to create a more normal appearance.  Based upon review of the photographs and examination, the proposed surgery would create more than a minimal improvement and thus should be considered reconstructive surgery.  All told, the requested abdominoplasty is reconstructive in nature.  Final Result: The reviewer determined that the requested services are reconstructive in nature 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested residential substance use rehabilitation services for treatment of his substance use disorder.   Findings:  The physician reviewer found that although addiction specialty services are indicated for this patient, the clinical documentation does not demonstrate the medical necessity of residential treatment level of care services. The psychosocial assessment reported a normal mental status examination. The patient appeared healthy and his thought processing was normal. There was no mention of suicidality, psychosis, craving, withdrawal or medical illness. In addition, he was employed and had a loving family that supported his recovery.  He was not prescribed psychotropic medication. The patients diagnosis was deferred to a psychiatric evaluation that was not included for review. The treatment plan called for step down to a lower level of care, but there was no interpretative summary justifying the level of care. During the episode of illness, aside from a reported two-day attempt at outpatient services, the patient had not been treated in a less restrictive setting. This is significant since modern psychiatric practice favors treatment in the community as outcome measures and therapeutic gains are optimized in this environment, and there was no evidence to suggest that comprehensive services delivered in a less restrictive treatment setting would have been unsafe, inadequate or insufficient in re-establishing sobriety. Thus, the residential substance use rehabilitation services 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.  Credentials/Qualifications: The physician 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 insertion of a lumbar artificial disc for treatment of his medical condition.   Findings: The physician reviewer found that this patient presents with chronic back pain and vague lower extremity symptoms. He has no symptoms or signs of a lumbar radiculopathy with matching dermatomal and myotomal symptoms and findings (Ropper and Zafonte). In addition, there is a lack of documentation that he has failed conservative management including physical therapy, non-steroidal anti-inflammatory drugs (NSAIDs), pain management, or injections. Moreover, the records do not include a detailed physical and neurologic examination showing orthopedic and vascular causes for the patients pain have been ruled out. He has no evidence of recurrent disc herniation with imaging correlating with his history and examination and there are no signs or symptoms of spinal stenosis or neurogenic claudication. All told, the requested insertion of a lumbar artificial intervertebral disc is not medically necessary for treatment of this patients chronic back pain.Final Result: The reviewer determined that the requested surgery is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The physician reviewer is board certified in neurological 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.