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

Nature of Statutory Criteria/Case Summary: An enrollee has requested for negative pressure wound therapy for treatment of the enrollees medical condition.  Findings: Three physician reviewers found that the current medical evidence supports the services at issue in this clinical setting.  The medical literature has demonstrated that negative pressure wound therapy improves time to closure, decreases hospital days, improves control of wound drainage, and decreases pain.  This treatment has become the standard management for open wounds.  The services at issue were for this high-risk, immunocompromised patient with a large, infected wound.  In sum, negative pressure wound therapy was likely to have been more efficacious than other treatment options.Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three physician reviewers are board certified in surgery 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 laparoscopic hysterectomy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that this is a patient who has well documented history of severe dysmenorrhea that has not responded to conservative measures such as oral contraceptives and pain medications. Per the patients provider, palpation of the uterus produced pain. There is no evidence of endometriosis on laparoscopy. There is a fibroid but it is small and unlikely to be the cause of her pain. Degeneration could cause acute pain, but this would not explain her years of pain.  The small ovarian cyst is likely functional and also would not cause the pain at issue.  The cyclic nature and lack of bowel or bladder symptoms make gastrointestinal or urologic causes remote. A more likely diagnosis is either severe dysmenorrhea, and/or adenomyosis, both of which, will respond to hysterectomy. Adenomyosis is often diagnosed in women at the end of their reproductive years, is frequently associated with the presence of fibroids, and the diagnosis is only definitively made on microscopic examination of the uterus after hysterectomy. In sum, the pattern and location of the pain makes it likely that the pain is uterine in etiology and that removal of the uterus would likely resolve the patients issues. For all these reasons stated above, the requested laparoscopic hysterectomy is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested procedure is 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 obstetrics and gynecology 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 the enrollees 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 nonliver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per guidelines, treatment-naive genotype 1 patients should be treated with Harvoni. Non-cirrhotic patients with viral load of less than 6,000,000 IU/mL, such as this patient, can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials (Kowdley, et al; Afdhal, et al). AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment (Jezequel, et al). For these reasons, the requested treatment with Harvoni for eight weeks is supported as medically necessary for the treatment of this patients hepatitis C infection.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The 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 Tylenol No.4 and morphine 3 times per day for treatment of the enrollees medical condition.  Findings: The physician reviewer found that based on the documentation submitted for review, Tylenol No.4 and morphine have not been established as medically necessary for treatment of the patients medical condition. Review found the provider recommends trigger point injections. Trigger point injections address hyperirritability in the muscle, that when compressed, is locally tender, and if sensitized, gives rise to referred pain and tenderness. In addition, there are many physical therapies that are used in the management of myofascial pain and the majority involves the application of pressure or stretch or both at the relevant myofascial trigger points. In this case, there is a lack of documentation demonstrating that the patient has trialed non-opioid medications, such as muscle relaxants. In addition, the providers recommendation for trigger point injections is medically reasonable and appropriate in this clinical setting. Given the above, the requested medications are not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the requested medications 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 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.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for treatment of the enrollees breast exam.  Findings: Three physician reviewers found that the digital breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages it brings radiologists in interpreting mammograms. This tomographic method often allows the radiologist to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in biopsies and callbacks and increase in diagnostic accuracy and detection of small cancers compared to studies using two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual mammography was likely of more benefit 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. 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 digital breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the presence of breast implants is not an indication for breast tomosynthesis. However, the patient has breast tissue that has been described as being heterogeneously dense. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Therefore, in this clinical setting the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Two reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three 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 OxyContin 20 mg tablet for treatment of the enrollees medical condition.  Findings: The physician reviewer found that from the date of the initial accident with the time period of over six months of pain, this patients symptoms could be considered chronic. The patient also continues to present with active pain issues. Per the Argoff review article, noting specifically chronic non-cancer pain, short acting and long acting opioid have been found to be effective. The review also noted that therapies should be tailored to the individual patient and that short acting opioids may be appropriate for some patients with chronic non-cancer pain. In the Nicholson article, the author states, opioid doses should be titrated according to agent-specific schedules to maximize pain relief and maintain tolerabilityTolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. Peppin and colleagues recommended urine drug testing prior to administration of opioids. In this patients case, the documentation provided did not include a urine test or a narcotic contract. Thus, the requested OxyContin 20 mg two times per day absent a narcotic contract and urine drug testing is not medically indicated. The medical literature recommends identifying aberrant substances prior to any changes in medications. As such, OxyContin 20 mg tablet extended release two times per day is not medically necessary for 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 physician 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.
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 risk for breast cancer.  Findings: Three reviewers found that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use. Despite the lack of long-term studies proving an increased survival rate when tomosynthesis has been used as part of screening mammography, the American College of Radiology (ACR) urged the technique be removed from the investigational category due to the advantages this new tomographic technique brings to radiologists interpreting mammograms. This technique often allows radiologists to separate dense glandular elements from underlying masses and architectural distortion resulting in a decrease in callbacks and increased detection of small cancers. Thus, the addition of tomosynthesis to the usual two dimensional protocol was likely of greater benefit to this patient than had her exam been done with two dimensional imaging alone. Accordingly, the 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 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 residential level of care services for treatment of the enrollees behavioral health condition. Findings: The physician reviewer found that the submitted documentation fails to establish the medical necessity of the services at issue. According to the documentation submitted for review, the patient was experiencing mild to moderate post-acute withdrawal syndrome (PAWS). The patient was not a danger to themselves or to others. The patient did not have emotional, behavioral, cognitive, or impulsive symptoms that would warrant residential level of care. The patient was motivated and appeared to be working with the treatment program. The patient was medically and psychiatrically stable. She had support systems in place. Although she continued to struggle with her emotions and required further treatment to help develop her coping skills, the structured environment of residential treatment was no longer medically necessary. The patient could have continued treatment at a lower level of care. Therefore, the residential level of care services have not been established as 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 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 shockwave therapy for treatment of the enrollees medical condition.  Findings: The physician reviewer found that Shockwave therapy was not and is not medically necessary for treatment of the patients medical condition. Extracorporeal shockwave therapy (ESWT) is among the accepted treatments for pain from calcifying tendinitis of the shoulder and has been suggested to be an effective treatment option before surgery, but only after failure of conservative treatments. The available noninvasive treatments include physical therapy, iontophoresis, deep friction massage, local application of non-inflammatory drugs, and oral non-steroidal anti-inflammatory medications. Needle irrigationaspiration of calcium deposits and a subacromial bursal steroid injection can also be considered. For this reason, shockwave therapy has not been established as medically necessary for treatment of the 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. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in physical medicine and rehabilitation and 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Cologuard stool testing for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that the Cologuard stool has not been established as medically necessary for evaluation of the patients medical condition. Conventional assessment of colorectal cancer (CRC) risk largely involves detection of non-dysplastic adenomatous polyps. Cologuard demonstrates inadequate sensitivity to detect precancerous lesions. Moreover, there is a lack of peer-reviewed literature to support the medical necessity of Cologuard testing in lieu of endoscopic evaluation for suspected source of blood in stool. All told, the testing at issue was not medically necessary for treatment of the patients medical condition.Final Result: The reviewer determined that the testing at issue was 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 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: The parent of an 11-month-old enrollee has requested developmental testing with interpretation for evaluation of the enrollees medical condition.  Findings: The physician reviewer found that according to De Kegel and colleagues, A congenital CMV [cCMV] infection is a risk factor for a delay in the early motor development. Follow-up will be necessary to gain insight into the exact cause of this motor delay and to define the predictive value of early motor assessment of cCMV infected children. Thus, congenital CMV has known implications on development and hearing. Children with congenital CMV require closer monitoring than other children on their development. The study by De Kegel and colleagues found that children with congenital CMV were more likely to have motor delays and require physical in the first 18 months of life and recommended monitoring development at 6, 12 and 18 months. Milewska-Bobula and colleagues found considerable developmental delays even in mildly symptomatic children with congenital CMV and recommended longer term close monitoring of development even into school age. Celikel and colleagues found that 48% of children with congenital CMV will have implications on their long-term development and recommended long-term follow-up. Thus, children with congenital CMV require a higher level of screening. In this case, the patient presents with congenital CMV and requires ongoing neurodevelopmental follow-up at a tertiary care provider. Based on the support in the peer-reviewed literature, the developmental testing with interpretation and report has been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the testing at issue was medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for digital breast tomosynthesis for evaluation of the enrollees medical condition. Findings:  The physician reviewers found the use of mammography plus tomosynthesis in a screening environment resulted in a significantly higher cancer detection rate and enabled the detection of more invasive cancers.   Integrated two-dimensional and three-dimensional mammography improves breast cancer detection and has the potential to reduce false positive recalls. Thus the literature supports the use of breast tomosynthesis over conventional mammogram due to improved cancer detection rate. Final Result: Two of 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: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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.