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

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the lower back and leg for evaluation of his low back pain with radiation across the back and to calf. Findings:  The physician reviewer found that according to the literature, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. The literature noted that evidence indicates that immediate, routine lumbar spine imaging in patients with low back pain and without features indicating a serious underlying condition did not improve outcomes compared with usual clinical care without immediate imaging. In addition, the literature reported that clinicians should refrain from routine, immediate lumbar imaging in patients with acute or subacute low-back pain and without features suggesting a serious underlying condition. Thus, the requested MRI of the lower back and leg are not medically necessary for evaluation of this patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedures are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested Rituxan infusion for treatment of her dermatomyositis.  Findings:  Two physician reviewers found that dermatomyositis is a rare disease according to the National Institutes of Health. The medical records document that this patient has failed various standard treatments. However, the records document that the only treatment to which she has responded has been Rituxan. There is adequate data demonstrating the safety and effectiveness of Rituxan in this clinical setting. Thus, the requested Rituxan infusion is likely to provide this patient with greater health benefits than any available therapy. Final Result: Two reviewers determined that the requested medication is 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 reviewers are board certified in internal medicine with sub-specialty certification in rheumatology 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 Sovaldi and Daklinza for 24 weeks for treatment of his chronic hepatitis C virus genotype 3.   Findings:  The physician reviewer found that according to 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 life expectancy less than 12 months due to non-liver-related conditions. Per the guidelines, patients with cirrhosis are considered high priority for treatment. In cirrhotic treatment naive genotype 3 patients, therapy is recommended with Sovaldi and Daklinza for 24 weeks. This is based on the ALLY-3 and EUCUP trials, which demonstrated a higher cure rate with 24 weeks than with 12 weeks of therapy, and a cure rate of 88% in cirrhotic patients. The AASLD/IDSA guidelines state that the alternative regimen, which requires interferon, has similar efficacy in cirrhotic patients but increased adverse event rates and monitoring requirements. For these reasons, the requested treatment with Sovaldi and Daklinza for 24 weeks 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. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested radiofrequency neurolysis for treatment of his sacroiliitis and lumbosacral spondylosis without myelopathy.  Two physician reviewers found that radiofrequency neurolysis is not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. According to the documentation submitted for review, the patient is fused at L3-4 and L5-S1. The provider recommended a radiofrequency at L5-S3. The peer reviewed literature does not support radiofrequency ablation at levels that are already fused. The medical literature does provide evidence for the utility of sacroiliac joint rhizotomy for pain due to lumbosacral degenerative disc disease. However, the procedure is not likely to be beneficial in patients who have had spinal fusion where the medial and lateral branch nerves are disrupted. Given the provider has requested radiofrequency neurolysis at a level that is already fused, the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Final Result:  Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: One reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing.  Two reviewers are board certified in anesthesiology and pain medicine 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:   An enrollee has requested residential treatment center (RTC) level of care services for treatment of her bipolar disorder, eating disorder, and polysubstance abuse.  The physician reviewer found that according to the American Psychiatric Association (APA) guidelines, services available for treating eating disorders can range from intensive inpatient programs (in which general medical care is readily available) to residential and partial hospitalization programs to varying levels of outpatient care (in which the patient receives general medical treatment, nutritional counseling, and/or individual, group, and family psychotherapy). The APA guidelines also note that in determining a patients initial level of care or whether a change to a different level of care is appropriate, it is important to consider the patients overall physical condition, psychology, behaviors, and social circumstances rather than simply rely on one or more physical parameters, such as weight. The review of submitted documentation does not reveal any evidence that the patients symptoms could not have been treated at lower level of care. All told, RTC level of care was not medically necessary for treatment of this patients medical condition.   Final Result: The reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested computed tomography microwave ablation for treatment of her medical condition. Findings:  Two physician reviewers found that one of the controversial areas of cancer treatment regards the local treatment of metastatic cancer.  There is data regarding the management of oligometastases, or single or very few metastases.  Solitary liver and/or lung metastases have been the particular focus of this interest.  The most common treatment in this situation has been surgical excision, but there is data using ablative techniques in the liver.  However, most of this data has been in colorectal cancer, and not in breast cancer.  It is believed that the most appropriate use for such techniques would be in patients whose metastatic disease is limited to the liver, which is rarely the case with breast cancer.  It is not clear whether the treatment of such metastases improves survival.  In carefully selected cases, surgical resection of an isolated liver metastasis in breast cancer has been associated with long survival. An alternative to surgical excision has been microwave and other ablation techniques.  However, the overall consensus is that such techniques can be considered if there is a solitary metastasis, no evidence of metastases elsewhere, good performance status, and a long disease-free interval.  Such criteria are not demonstrated in this case, as she has multiple lesions and metastases.  Therefore, the requested computed tomography microwave ablation is not likely to be of greater benefit compared to systemic therapy.Final Result: Two reviewers determined that the requested services are not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: Reviewers 1, 2, and 3 are board certified in internal medicine with sub-specialty certification in medical oncology 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested magnetic resonance imaging (MRI) of the left breast for evaluation of her medical condition.  Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the requested services.  In the last several years, there has been significant growth in the use of breast MRI.  Breast MRI has an important role in both screening and diagnostic settings.  However, from a screening perspective, there is no indication that this patient meets the criteria for being at high-risk for developing breast cancer, as defined as having a 20-25% likelihood of developing the disease.  MRI studies of the breast are highly sensitive but have a relatively low level of specificity.  The literature consistently does not recommend the use of breast MRI as a replacement for routine breast mammography and ultrasound.  This patient has had stable mammograms, which is probably the best indication that she does not have tumor.  The most valuable tool in interpreting a mammogram is a comparison with an older mammogram, especially when there are no palpable masses.  There is a lack of evidence supporting the use of MRI as a surveillance tool rather than conventional mammography.  This patient reports severe discomfort in her left breast.  Breast pain is rarely associated with breast cancer, especially without a recognizable mass.  In this patients case, there is no reason to doubt the accuracy of the mammogram.  In conclusion, there is there is insufficient data to support the requested services in this patients case.  All told, the requested MRI of the left breast is not medically indicated for the evaluation of this patient.  Final Result: The reviewer determined that the requested services are not medically necessary for evaluation of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: The reviewer is board certified in diagnostic radiology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested Sovaldi and ribavirin for 12 weeks for treatment of his chronic hepatitis C virus genotype 2b.  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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions.  Per the guidelines, patients with genotype 2 hepatitis C should be treated with daily Sovaldi and weight-based 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. For these reasons, the requested treatment with Sovaldi and ribavirin for 12 weeks 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. 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 intensive outpatient treatment services for treatment of her behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Based on the documentation provided, specialty services at the intensive outpatient program level of care were indicated as the patient had not yet consolidated the treatment gains necessary to succeed in a less restrictive setting.  During the disputed timeframe, the patient was engaged in active treatment delivered in accordance with a multidisciplinary treatment plan.  Despite these interventions, the patient continued to struggle.  Treatment thereafter emphasized transitional planning and included closure sessions aimed at facilitating a smooth and successful transition to outpatient care.  However, intensive outpatient program treatment was no longer reasonably expected to improve her condition.  All told, intensive outpatient treatment services initially provided were medically necessary, but not thereafter.  Final Result: The physician reviewer determined that the services at issue were 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 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested genetic testing for evaluation of her medical condition.  Three physician reviewers found that there is a lack of support for the services at issue in this clinical setting.  The role of thrombophilia in first trimester miscarriage remains unclear.  According to American College of Obstetricians and Gynecologists, although thrombophilias commonly are thought of as causes of early pregnancy loss, only antiphospholipid syndrome consistently has been shown to be significantly associated with early pregnancy loss.  This patient does not have antiphospholipid syndrome based on history and other laboratory tests.  The genetic testing in question has not been shown to be of benefit in patients with first trimester losses.  All told, genetic testing was not likely to have been of greater benefit than other modalities. Final Result: Three 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 reviewers are board certified in obstetrics and gynecology 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 a chest computed tomography (CT) scan (CPT 71250) for evaluation of her medical condition.  Three physician reviewers found that the requested services are likely to be more beneficial for evaluation of the patients medical condition than available standard modalities. The peer-reviewed literature supports the requested services in this clinical setting.  According to Ma and colleagues, there is sufficient support for the requested services in this patients case.  All told, the requested chest CT scan is likely to be of greater benefit than other modalities for evaluating this patient. Final Result:  Three reviewers determined that the requested services are likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: All three reviewers are board certified in 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 the Veracyte Afirma gene test for evaluation of her medical condition. Three physician reviewers found that while a fine needle aspiration biopsy of a suspicious thyroid nodule is typically an accurate means of assessing whether the nodule is benign or malignant, approximately 15% of fine needle aspiration biopsy results are considered to be indeterminate.  Until recently, the only way to establish whether the nodule was thyroid cancer was via surgical excision, even though the majority of the cases turn out to be benign.  The Afirma Thyroid FNA Analysis utilizes a gene expression classifier in order to help determine the likelihood of malignancy of nodules with indeterminate cytology on fine needle aspiration biopsy, thereby decreasing the need for unnecessary surgeries.  Because it is very sensitive and has a high negative predictive value, a negative Afirma result is rather suggestive of a benign nodule and can therefore preclude such surgical procedures.  All told, the Veracyte Afirma gene test was likely to have been superior over other modalities for evaluating this patient.  Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications:  All three reviewers are  board certified in internal medicine with sub-specialty certification in endocrinology, diabetes and metabolism and are actively practicing. All three reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Lazanda (fentanyl) nasal spray for treatment of her breakthrough pain. The physician reviewer found that Lazanda (fentanyl) nasal spray is not medically necessary for treatment of this patients chronic non-malignant pain. The current standard of care for chronic pain associated with disc herniation is treatment in a multidisciplinary practice to include physical therapy, massage therapy, behavioral therapy, and injections to help reduce pain. There are a variety of anticonvulsant medications and anti-depressants considered adjunctive to this therapy. High dose opioids are associated with a high risk of dependence and tolerance and are therefore not recommended. Baron and McDonald reported that high dose and short acting opiates might contribute to pain sensitization via opioid-induced hyperalgesia, decreasing patient pain threshold and potentially masking resolution of a preexisting pain condition. In this retrospective study, the majority of patients undergoing detoxification of high dose opiates for chronic pain reported a significant decrease in pain at the end of the study, further supporting the theory of opioid-induced hyperalgesia. Ballantyne and Mao reported that prolonged use of high dose, short-acting opiates might induce tolerance, and abnormal pain sensitivity. The aim of current guidelines is to protect patients from the adverse effects of opioid therapy. It is thus in this patients best interest to wean off opioids and continue in a multidisciplinary program. Consistent with these findings, the requested Lazanda (fentanyl) nasal spray is not medically necessary.  Final Result: The reviewer determined that the requested medication is 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 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.