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

Nature of Statutory Criteria/Case Summary: An enrollee has requested bilateral breast tomosynthesis for evaluation of her medical condition. Findings: Two physician reviewers found that the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. The American College of Radiology (ACR) statement has urged tomosynthesis be removed from the investigational category due to the advantages it brings to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular material from underlying architectural distortion resulting in a decrease in callbacks, increase in diagnostic accuracy and increase in detection of small cancers when compared to two-dimensional imaging alone. Thus, the addition of tomosynthesis to the usual two-dimensional imaging protocol was likely of greater benefit to the patient than had the exam been done using 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. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested colorectal cancer for evaluation of the enrollees medical condition. Findings: Two physician reviewers found that the evidence regarding healthcare outcomes of Cologuard is lacking at this time.  Cologuard has been approved to test for colon cancer, and can detect most adenomas if they have high-grade dysplasia.  However, although Cologuard may be able to determine that cancer has already developed, it cannot detect and remove polyps or precancerous lesions so that cancer does not develop.  The long-term health outcomes of foregoing regular polyp removal and instead using Cologuard have not been determined.  Health outcomes using Cologuard have not been compared over the long-term with other screening methods for colon cancer.  Based on the current evidence, the services at issue were not likely to have been superior over other methods of evaluating this patient.Final Result: Two reviewers determined that the services at issue were 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: Experimental/Investigational
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has advanced lipoprotein testing for evaluation of her heart disease. Findings: Two reviewers found that in current evidence-based practice, there is insufficient data to support the use of advanced lipoprotein analysis in this clinical setting. While some researchers have advocated use of the advanced lipoprotein analysis for evaluation of cardiovascular risk to help make treatment decisions for patients with hyperlipidemia, the guidelines of the American College of Cardiology Foundation (ACCF) do not support the use of advanced lipoprotein analysis. There is insufficient data, according to the ACCF, to document benefit for the advanced lipoprotein assay above the basic lipid profile. Therefore, the advanced lipoprotein testing performed 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 service 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 cardiovascular disease and is 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested dermatology and related services on an emergent or urgent basis. Findings: The physician reviewer found that the submitted documentation demonstrates that a prudent layperson would not believe he was experiencing an emergency medical condition on the dates in dispute. Based on the records provided the patients presentation on the dates in dispute was not consistent with the above definition of an emergency medical condition. The patient presented for evaluation and treatment of psoriasis and vitiligo. Psoriasis is a chronic disease that can be associated with flares and remissions. In this case, the documentation submitted for review does not describe any symptoms of pain or indication he was suffering from a serious medical condition that was likely to place the patients health in serious jeopardy, cause serious impairment to body functions or cause serious dysfunction to a body organ or part. Thus, the services provided did not meet prudent layperson criteria for emergency care. Moreover, it has not been established that criteria for urgently needed services were met on the dates in dispute. The patient presented with psoriasis and vitiligo and was appropriately treated for these conditions. However, there is a lack of documentation supporting that the services at issue were necessary to prevent serious deterioration of the health of the patient for which treatment cannot be delayed until the he returned to the Plans service area. Based on the documentation submitted for review a prudent layperson in a similar situation would not have believed urgent medical attention was necessary to prevent serious deterioration of ones health. In sum, based on the patients clinical presentation on the patient did not meet prudent layperson criteria for urgently needed services.  Final Result: The reviewer determined that the patients symptoms did not meet prudent layperson criteria for emergency care or urgently needed services. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in dermatology 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 intravenous immunoglobulin (IVIG) therapy for treatment of her medical condition.   Findings:  The physician reviewer found that there is limited literature to indicate that painful neuropathy in patients with diabetes can be effectively treated with IVIG. This patient is documented to have painful polyneuropathy, supported by exam and referenced by an electromyogram (EMG) but painful polyneuropathy is a common complication of diabetes and may not be indicative of chronic inflammatory demyelinating polyneuropathy (CIDP). The cerebrospinal fluid (CSF) features associated with CIDP would typically include elevated protein, normal cellularity which were not reported for this patient. Also, there is no mention of the typical EMG findings associated with stiff person syndrome (SPS) and there is no rigidity reported. Anti-GAD (Glutamic Acid Decarboxylase) antibodies are seen in patients with type 1 diabetes in up to 80% without SPS, in but a small fraction. First line therapy for neuropathic pain typically includes gabapentin, Lyrica, and tricyclic medications such as amitriptyline. Based on the records provided, it does not appear the patient has exhausted first line therapies for treatment of her neuropathic pain. All told, the requested IVIG therapy is not medically necessary for treatment of this patients medical condition.  Final Result: The reviewer determined that the requested therapy 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 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 a cervical epidural (nerve block), pic line with feeding tube, Fentanyl patch, morphine, Toradol and Percocet for treatment of her medical condition.  Findings:  The physician reviewer found that The American Society of Interventional Pain Physicians (ASIPP) guidelines recommend that a comprehensive assessment of a patient should be initiated prior to or in the maintenance of chronic opioid therapy of 90 days or longer. The standard of care requires a complete history, physical examination, and a comprehensive work up of the origin of the pain which may include various testing modalities. Urine toxicology screening is also required prior to starting opiates (Manchikanti, et al). Based upon the submitted records the patient has not been evaluated for her pain recently. While there is a record showing a recent visit with a social worker from the hospital, there is no record to indicate the patient was seen by her primary care provider or a pain management provider. The records also show she was scheduled for three pain management appointments but these appointments were canceled by the patient. There is no documentation as to urine toxicology screening, physical examination or pain management consultation. The patient has not undergone a comprehensive assessment in order to determine and identify appropriate pain medication therapy. For these reasons and per accepted standards of care, the requested therapies are not medically necessary for treatment of this patients medical condition.   Final Result: The reviewer determined that the requested therapies 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-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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Sovaldi and ribavirin for treatment of his hepatitis C virus genotype 2.  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. This applies regardless of fibrosis stage or viral load. Per AASLD and IDSA guidelines, treatment naive genotype 2 patients should be treated with Sovaldi and ribavirin 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 2 regardless of fibrosis stage (Zeuzem, et al; Lawitz, et al; Jacobson, et al). The AASLD/IDSA guidelines do not recommend any other regimens for ribavirin-eligible genotype 2 patients. The guidelines also cite data showing increased survival with earlier treatment (Jezequel, et al). For these reasons, the requested treatment with Sovaldi and ribavirin is supported as medically necessary for the treatment of this patients hepatitis C infection. Final Result: The reviewer determined that the requested medications are medically necessary for treatment of the patients medical condition.  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 Xifaxan for treatment of his medical condition. Findings:  The physician reviewer found that the current medical evidence supports the requested medication in this clinical setting.  This patient has irritable bowel syndrome with diarrhea (IBS-D).  The U.S. Food and Drug Administration (FDA) has approved Xifaxan for the treatment of IBS-D, and the medication has proven safe and effective in randomized placebo-controlled trials for IBS-D.  Although the patient has used Xifaxan before, clinical studies and the FDA approval do support use of Xifaxan again for two similar courses a specific period of time apart.  For these reasons, the requested Xifaxan is medically necessary for the treatment of this patient. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Donnatal for treatment of her inflammatory bowel disease (IBD).  Findings:  The physician reviewer found that Donnatal is used to treat abdominal pain, bloating and cramps in patients with IBD. It is composed of atropine sulfate, hyoscyamine sulfate, phenobarbital, and scopolamine hydrobromide. The records indicate that this patient has tried and failed numerous agents and has a contraindication to the use of Lomotil. Further, the patient is currently maintained on four other pain medications. Donnatal is a combination product, which will prevent the patient from having to take four additional pain medications to control her condition. The combination product Donnatal is appropriate, has provided this patient with functional benefit, and is therefore medically necessary. Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
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 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, 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.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   The parent of an enrollee has requested residential treatment center services for treatment of the enrollees behavioral health condition.  Findings:  The physician reviewer found that based on the documentation submitted for review, the residential treatment center services at issue were not and are not medically necessary for treatment of the patients behavioral health condition. Per the Health Plans clinical documentation, the patient is not psychotic, suicidal, or homicidal. The submitted documentation indicates that the patient has insight and judgment and is not delusional, and he does not have symptoms of withdrawals that require 24-hour supervision. Given the above, the medical necessity of the services at issue has not been established.  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 psychiatry with sub-specialty certification in child and adolescent 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 authorization and coverage for an implant neurostimulator for treatment of his medical condition.   Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested device.  Spinal cord stimulation is a late or last resort for pain control and has very specific indications. The current medical evidence does not support an implant neurostimulator in this clinical setting.  This patient does not have complex regional pain syndrome as defined by the American Academy of Neurology.  He has also not had maximum medical therapy.  All told, the requested device is not medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested device 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 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 a heart positron emission tomography (PET) scan for evaluation of his medical condition.  Myocardial ischemia is generally evaluated by imaging the patient both at rest and after stress. The stress can be performed via a treadmill or can be done pharmaceutically.  In patients with suspected ischemia, simply visualizing coronary artery anatomy is insufficient, as patients may have narrowing of the coronary vessels without ischemia, or alternatively, they may have ischemic changes with vessels that are not grossly narrowed. Hence, routine cardiac catheterization does not solve the clinical problem. To better evaluate ischemic changes, a routine procedure would be a single photon emission computed tomography (SPECT) scan utilizing sestamibi. However, one of the problems with a sestamibi SPECT scan is poor spatial resolution. Maddahi and colleagues reported that PET myocardial perfusion imaging is increasingly being used for noninvasive detection and evaluation of coronary artery disease. As the radiopharmaceuticals become more widely available, and in view of the significant improvement in spatial resolution, it is likely that PET cardiac scanning will become more widely utilized than SPECT scanning in this clinical setting. For these reasons, the heart PET was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.  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.