Persius/hicric huggingface dataset:
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested coverage for Anser IFX Prometheus Lab testing for evaluation of the enrollees Crohns disease.  Findings: Two physician reviewers found that the Prometheus Anser IFX test is a quantitative measurement of serum infliximab (IFX) and anti-IFX antibodies. Some evidence exists that low serum levels of infliximab and/or the presence of antibodies to infliximab may play a role in primary or secondary response failures. Antidrug antibodies develop in a substantial number of patients and may be responsible for acute drug infusion reactions as well as delayed hypersensitivity reactions. In a large percent of patients who develop antibodies, such antibodies may disappear after continued treatment. The reasons for therapeutic failures remain unclear. Some evidence exists that low serum levels of infliximab or the presence of IFX antibodies have an adverse effect on the clinical outcome of a patients response to treatment. However, although there have been testimonials, there are few well controlled clinical trials to confirm that use of the Anser testing leads to improved patient outcomes or quality of life as opposed to the standard method of treatment (Nanda, et al). In addition, it has not yet been established whether the use of threshold levels aid in the discrimination of treatment response, nor has the optimal timing of when to measure antibody levels been established. While it can be argued in this patients case that detection of antibodies to infliximab would have contraindicated its restart, there was no indication for measuring serum levels of infliximab in this patient who had stopped the medication six months earlier. Thus, the Anser IFX Prometheus Lab testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two 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: All three physician reviewers are board certified in internal medicine with sub-specialty certification in gastroenterology 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for evaluation of current temporomandibular joint (TMJ) splint for adjustment or replacement. Findings:  The physician reviewer found that the submitted documentation and relevant literature demonstrates the medical necessity of the requested service. In general, conservative treatment for TMJ disorder is the first-line therapy for affected patients. This includes splint therapy. The patient has had success with splint therapy in the past. In this clinical setting an evaluation of the patient by a provider with experience in the management of TMJ is medically necessary. Such a provider can make a decision on continuation with splint therapy and asses her current appliance. Final Result: The reviewer determined that the requested service 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 oral facial and maxillary 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 authorization and coverage for CPT codes including, 64568 - incision for implantation of cranial nerve (eg. vagus nerve) neurostimulator electrode array and pulse generator; and 61885 - insertion or replacement of cranial neurostimulator pulse generator or receiver, direct or inductive coupling; with connection to a single electrode array. Findings:  Three physician reviewers found that the medical literature, VNS sends electric pulses to the left vagus nerve every few seconds and it is hypothesized that the subsequent modulation of certain neural tracts enhances serotonergic and noradrenergic innervation and possibly increases blood flow to critical brain structures which in turn alleviates clinical depression. In this case, the patient is diagnosed with bipolar disorder which is a highly-recurrent, lifelong and disabling mental illness. Her affective illness is consistent with treatment resistant depression. The patient has exhausted U.S. Food and Drug Administration approved treatments for bipolar depression. She has also trialed many off-label pharmacotherapies along with a course of electroconvulsive therapy. The VNS device was originally implanted in 2007. Such devices have an approximate duration of operability ranging from 6 to 11 years. Thus, the need for replacement at this time is not unexpected. The treatment has been well-tolerated for the past nine years. In addition, the treatment is recommended by the patients treating psychiatrist. Final Result: Three 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 physician reviewers are board certified in psychiatry 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: The parent of an enrollee has requested coverage for continuation and increased frequency of direct applied behavioral analysis (ABA) therapy for treatment of the enrollees autism.  Findings: The physician reviewer found that ABA has been shown in the medical literature to be effective for children with autism spectrum disorders. Reichow and colleagues found that early intensive behavioral intervention is effective to increase IQ, and improve communication and adaptive skills. In this case, the patient has been treated with ABA therapy which has been effective for treating his communication, executive function and adaptive skills. Per the most recent progress note he has demonstrated mastery in inhibition of problem behaviors and stimulus orientation. In addition, he has shown mastery of responding to social cues. However, he continues to have non-compliance, emotional outbursts and vocal protest. The goals and curriculum of ABA are specifically designed to teach and ameliorate the core symptoms of autism including social deficits, communication deficits and adaptive skills. The Health Plans authorization of a reduction of hours per month of direct ABA therapy and of supervision is not indicated for this patient. Greatly reducing ABA services increases the likelihood of regression of skills already obtained. In this case, a portion of the requested ABA therapy, per month supervision and per month parent training was and is medically necessary for treatment of the patients autism.Final Result: The reviewer determined that a portion of the services at issue were and is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in developmental-behavioral pediatrics 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 authorization and coverage for shoe orthotics for treatment of the enrollees bilateral foot pain. Findings:  The physician reviewer found that the submitted medical documentation noted that this patient has bilateral foot pain with diagnoses of posterior tibial tendinitis, peroneal tendinitis, sinus tarsitis, and questionable stress fracture of calcaneus. The use of custom orthotics is the standard of care for treatment of bilateral foot pain as experienced by this patent. Custom orthotics are used in podiatry frequently to correct the abnormal biomechanics of patients feet, thereby alleviating abnormal strains of tendons, muscles, and ligaments, such as in this case.  The correction of the abnormal biomechanics subsequently alleviates patients pain. In this particular case, her bilateral foot pain was well documented. This patient was diagnosed with bilateral feet pain, inflammation of the sinus tarsi and a questionable stress fracture of the calcaneus. Custom shoe orthotics will correct the abnormal biomechanics of this patients foot thereby alleviating her bilateral foot pain. Final Result: The reviewer determined that the requested devices 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 podiatry 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 reimbursement for the digital breast tomosynthesis. Findings:  Three physician reviewers found that based on the documentation submitted for review, the patient underwent a screening mammogram on 2/9/16. There was no tomosynthesis performed on this date. The digital breast tomosynthesis performed on 2/10/16 was clinically indicated. Tomosynthesis has been shown to better identify and characterize masses, especially when it unclear whether a mass is actually present. Final Result: Three reviewers determined that the diagnostic procedure at issue was 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Nuvigil. Findings:  The physician reviewer found that the submitted records and relevant literature fails to demonstrate the medical necessity of the requested medication. The documentation provided for review does not support the diagnosis of shift work sleep disorder. In addition, there is a lack of documentation showing that the patient is employed in an occupation which necessitates shift work. There is also a lack of evidence showing the presence of other sleep disorders such as obstructive sleep apnea or narcolepsy. 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 reimbursement for inpatient psychiatric hospitalization services. Findings:  The physician reviewer found that due to the persistent affective symptom complex with disordered thought processing and violent behavior in context of autism spectrum disorder, a conservative psychiatric hospital stay was to be expected. Thus, the inpatient services provided in this case were reasonably expected to improve the patients condition and prevent a more serious episode of illness. Bipolar disorder is a chronic and debilitating mental illness. It is associated with poor clinical outcomes and erratic behaviors. The patient had been on a downward trend since late 2015. He was hospitalized earlier in 2016 and was not responding to outpatient treatment services. Upon presentation, the patient was violent, delusional and hypomanic. Although not suicidal, he was determined to be gravely disabled and a potential risk to others. During the admission, nursing notes described this patient as anxious, irritable and depressed and irritable with a flat affect . The patient was noted to be labile and focused on discharge , aggressive with a restricted affect , and disorganized, labile, and irritable. The psychiatrists documentation noted ongoing grandiosity, delusional thinking and abysmal insight with no means to support himself. His family was supportive but not sympathetic to the patients unrealistic plans while his receptiveness to aftercare plans changed frequently. During the course of the admission, the patient was engaged in active treatment consistent with evidence-based practice. He participated in group and milieu therapies, and received individual services as well. His medication regimen was optimized. The patients family was involved throughout the course of the hospitalization.  His delusional complex was clearing. He was able to interact appropriately with his father and brother. Retaining the patient on the unit to consolidate these gains and solidify an aftercare plan was consistent with good psychiatric practice and more than likely reduced the likelihood of prompt re-admission. 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 reimbursement for residential treatment center services for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation does not support the medical necessity of the services at issue. This patient no longer required continued treatment at the residential treatment level of care and could have been treated in a lesser restrictive setting. This patient denied any suicidal or homicidal ideation.  He did not endorse auditory or visual hallucinations. He was not a danger to self or to others.  The patient was not exhibiting symptoms of withdrawal. His mood was noted as stable, calm and cooperative. As such, this patients issues did not require the structured environment of a residential care treatment setting. This patient could have received treatment in a lesser restrictive setting. For, these reasons, the residential treatment center services provided were not medically necessary for 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 psychiatry with sub-specialty certification in geriatric 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 reimbursement for digital breast tomosynthesis performed for the evaluation of the enrollees medical condition. Findings:  Three physician reviewers found that the patient had a two month history of right breast pain. She underwent a diagnostic mammogram consisting of a combination two dimensional and three dimensional tomosynthesis examination. There were no prior images for comparison.  In addition to the mammogram, she had a targeted sonogram of her right breast. There were no masses, areas of suspicious calcifications, or areas of architectural distortion.  Her breasts were described as being heterogeneously dense. The Health Plan has denied reimbursement for digital breast tomosynthesis.  Per the Health Plan, the service at issue was investigational for the evaluation of this patient. Breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, the presence of breast pain is not, in itself, a reasonable indication for tomosynthesis.  Breast pain, or mastodynia, is an unusual presentation of breast cancer. However, the patients breasts have been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. In sum, digital breast tomosynthesis performed was likely to have been of greater benefit than other methods of evaluating this patient. Final Result: The reviewers have determined that the service at issue was 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for a panniculectomy performed for treatment of the enrollees pannus. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  This patient had a well-documented history of a symptomatic lower abdominal pannus, and she had failed reasonable conservative management.  Specifically, she had chronic rashes underneath her overlapping pannus that had failed conservative measures of attempted weight loss, proper hygiene and specific/typical dermatologic medical management.  In this clinical setting, a panniculectomy was likely to have improved her functional deficit.  The current medical evidence supports the services at issue in this patients case. The Health Plans basis for denying reimbursement for the panniculectomy was that the pannus did not hang below the middle of the groin.  This appears to be an arbitrary cut-off point and is not supported by medical literature.  This also ignores the overall clinical picture of this patient.  All told, the panniculectomy performed was medically indicated for the treatment of this patient. 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 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 reimbursement for digital breast tomosynthesis for the enrollees routine breast cancer screening. Findings:  Three physician reviewers found that breast tomosynthesis is a technique that was developed several years ago as a problem solving adjunct to routine mammography.  Applying the same basic concept as computed tomography (CT) scanning, the logic is that by separating the various layers of breast tissue, one can better detect abnormalities. This has been shown to be most useful in the evaluation of dense breasts.  In this particular patient, her breasts were initially described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from breast tomosynthesis.  The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor.  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.