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

Nature of Statutory Criteria/Case Summary:   An enrollee has requested  the LifeVest Wearable Cardioverter Defibrillator for treatment of her medical condition.  Two physician reviewers found that the current medical evidence has not demonstrated the superior efficacy of the requested device in this patients case.  The requested device in the setting of a newly diagnosed dilated cardiomyopathy has not been documented to positively impact mortality during the period of initial treatment.  If a patient fails to improve ejection fraction to greater than 35% after three months of maximally tolerated treatment, she would meet the criteria for placement of an implantable cardioverter defibrillator.  Per the submitted documentation, the patient was only being treated with a small dose of Coreg, she was not on an angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy, and she was not on a diuretic or aldosterone antagonist.  Therefore, she had not been subject to or failed three months of maximal therapy and did not meet criteria for wearable cardioverter defibrillator or implantable cardioverter defibrillator placement.  In addition, no mortality benefit has been demonstrated in such patients during this three month period when they are treated with a wearable cardioverter defibrillator.  Therefore, the requested LifeVest Wearable Cardioverter Defibrillator is not likely to be of greater benefit than other treatment alternatives.   Final Result: Two reviewers determined that the requested device is 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: All three reviewers are board certified in internal medicine with sub-specialty certification in cardiovascular disease 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: Urgent Care
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested surgical services on an emergent basis. The physician reviewer found that the patient presented with a well-documented clinical scenario of an infected implant that required emergency treatment. She was noted to have purulent fluid coming from her left breast, associated with an underlying prosthetic implant. The treating surgeon noted this fact with his initial evaluation and recommended a same day surgery to washout and remove the implant. His indication for surgery noted a left periprosthetic infection. The fact that the patient had been experiencing symptoms for several days does not lessen the severity of the situation. Further, while the patient did not present with evidence of fever or systemic infection, her condition could have lead to a systemic infection in the absence of immediate treatment. An article by Prince and colleagues discusses implant salvage after infection and exposure. According to the authors, The key change involves the timing of antibiotic treatment. The majority of our patients who undergo attempted salvage do so as soon as possible and preferably on the same day as their presentation. This supports the need for immediate treatment of presumed implant infection.  Based upon the submitted medical documentation, the patient had evidence of a significant infection associated with a breast implant and required immediate attention.  She was instructed that she had a significant infection and required immediate treatment. All told, a prudent layperson in the patients circumstances would have sought immediate medical attention.  Final Result: The reviewer determined that the patients symptoms met prudent layperson criteria for emergency care. 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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested actigraphy testing for evaluation of her sleep difficulties.   Two physician reviewers found that Taibi and colleagues noted that actigraphy offers an unobtrusive method for measuring sleep, but it appears to underestimate sleep disturbance, particularly at sleep efficiency levels below 73%, in older women with insomnia. Ancoli-Israel and colleagues reported that although actigraphy is not as accurate as polysomnogram for determining some sleep measurements, studies are in general agreement that actigraphy, with its ability to record continuously for long time periods, is more reliable than sleep logs which rely on the patients recall of how many times they woke up or how long they slept during the night and is more reliable than observations which only capture short time periods. Actigraphy can provide information obtainable in no other practical way. However, this patients records include complaints of sleep problem with otherwise normal exam and reported normal MSLT and polysomnogram. Based on current peer-reviewed publications, there is no indication that actigraphy would offer any new information from a diagnostic standpoint compared to the normal studies already performed. As such, the medical records do not support the addition of actigraphy as likely to have been 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 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 internal medicine and neurology 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: Urgent Care
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested services on an emergent or urgent basis.   The physician reviewer found that review of the submitted documentation demonstrates that a prudent layperson would not have sought immediate medical attention during the period in question. Upon review of the submitted medical records, the patient presented with a history of biopsy proven polymyositis. The medical records demonstrate normal visits and exam but slightly worsening CPK levels. Although there is some evidence of worsening on labs, her levels were not the tenfold increase typically seen with very active disease and ESR was normal. The records do not demonstrate weakness or difficulty breathing or other signs of acute distress. All told, there is a lack of evidence the patient was exhibiting signs and symptoms during the disputed period that would lead a prudent layperson to believe she was experiencing an emergency medical condition requiring immediate attention. Thus, the requested services did not meet prudent layperson criteria for emergency care.  Further, it has not been established that criteria for urgently needed services were met on the dates in dispute. In this case, the records fail to document a serious worsening of the patients condition during the dates of service at issue. The patient sought treatment for a chronic condition and there is a lack of evidence she was experiencing complications of her existing condition. The records do not establish that she had a significant clinical worsening requiring immediate care before she returned to the Plans service area. In sum, based on the patients clinical presentation she did not meet prudent layperson criteria for urgently needed services. The Health Plans denial should be upheld.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 internal medicine with sub-specialty certification in rheumatology 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 a knee ankle foot orthotic (KAFO) leg brace for treatment of her post-polio syndrome. Findings:  The physician reviewer found that in the case of this patient, there is documentation of prior use of a KAFO. The patient has had long-standing post-polio syndrome which has resulted in lower extremity paraplegia. Orthoses are considered standard of care in the management of gait abnormalities due to neurologic conditions. KAFO devices can be utilized to allow a patient to have a safer gait when the patient is unable to dorsiflex the ankle. The medical literature suggested that a carbon composite knee ankle foot orthosis is more efficient than the conventional metal and leather combination used in older models. Another study documents the benefit of a carbon fiber KAFO in improving functional ambulation. Both studies describe the beneficial effects of the KAFO in allowing those with lower extremity weakness an ability to walk by activating more proximal groups. All told, the requested KAFO is considered standard of care and is medically necessary for treatment of this patients medical condition.Final Result: The reviewer determined that the requested equipment 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 physical medicine and rehabilitation 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 magnetic resonance imaging (MRI) of the right foot for evaluation of his suspected osteomyelitis. Three physician reviewers found that in the medical literature, Pineda and colleagues noted that MRI allows early detection of osteomyelitis and assessment of the extent of involvement and the activity of the disease in cases of chronic bone infection. The authors further state that MRI is considered the most useful imaging technique to evaluate suspected osteomyelitis because of its ability to demonstrate changes in the water content of bone marrow with an excellent structural definition and spatial resolution. MRI is highly sensitive for detecting osteomyelitis as early as 3 to 5 days after the onset of infection. Kothari and colleagues reported that nuclear medicine and MRI are the most sensitive and most specific imaging modalities for the detection of osteomyelitis. All told, the peer-reviewed medical literature supports the MRI of the right foot as likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Final Result: Three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: All three reviewers are board certified in diagnostic radiology and are actively practicing. All three reviewers are experts 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 the graft product, acellular dermal matrix (ADM) implantation utilized during surgery for treatment of her fracture of dislocation of left fourth proximal interphalangeal joint with volar plate involvements and left carpometacarpal arthritis. Three physician reviewers found that Ellis and Kulber noted that 'upper extremity surgeons have long been challenged with finding the best tissue replacement for weakened, ruptured, or diseased tendons and ligaments. Kokkalis and colleagues described an alternative to using native tendon by reporting the use of acellular dermal matrix to suspend the first metacarpal, thereby eliminating donor-site morbidity. Thus, AlloDerm has been used in an attempt to replace the use of autologous tendon tissue for the interpositional graft. However, from a review of the literature, this has not been sufficiently studied to replace generally accepted treatment for CMC arthroplasty. Accordingly, the graft product, ADM implantation was not likely to be more beneficial for treatment of the patients medical condition than any available standard therapy.  Final Result: Three reviewers determined that the services at issue were 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 orthopedic surgery and is actively practicing. Two reviewers are board certified in plastic surgery 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 magnetic resonance imaging (MRI) of the lumbar for evaluation of her back pain.  The physician reviewer found that the American College of Radiology (ACR) has established criteria for the evaluation of low back pain and defined several variants such as acute low back pain, post-traumatic low back pain, low back pain in cancer patients, low back pain with radiculopathy, low back pain in patients who have had prior lumbar surgery. The ACR reports that MRI is not warranted in the acute setting. However, the ACR criteria support the utility of MRI in the setting of low back pain with radiculopathy in which the patient is a candidate for surgery or other intervention. In the medical literature, Roudsari and Jarvik noted that the available guidelines emphasize the importance of a focused history and thorough physical examination before any imaging is ordered. In addition, all agree that for patients with acute low back pain and without any risk factor for serious spine abnormalities, imaging within the initial four to eight weeks should not be performed. Chou and colleagues noted that providers should evaluate patients with persistent low back pain and signs or symptoms of radiculopathy or spinal stenosis with magnetic resonance imaging (preferred) or computed tomography only if they are potential candidates for surgery or epidural steroid injection (for suspected radiculopathy) (strong recommendation, moderate-quality evidence). In this case, the patients back pain, sciatica, and symptoms were chronic and there were no immediate precipitating factors. All told, an MRI was medically necessary and directed this patients medical treatment.  Final Result: The reviewer determined that the services at issue were 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 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 afatinib (Gilotrif) for treatment of her lung cancer. Findings:  The physician reviewer found that the therapy of advanced non-small cell lung cancer has been revolutionized by the finding of epidermal growth factor receptor (EGFR) mutations in adenocarcinomas.  The mutational landscape of non-small cell lung cancer has significantly expanded in the past few years to encompass gain of function in multiple oncogenes with major prognostic and therapeutic consequences. Based on the current data, the literature supports the use of Gilotrif in this patient as medically necessary.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 oncology and hematology 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 enrollee has requested for surgery to open the eardrums and insert a tube (tympanostomy tube placement) for treatment of the enrollees medical condition.   Findings:  The physician reviewer found that otitis media is a common infection in children, typically preceded by a viral upper respiratory tract infection.  There is no gold standard for diagnosis, but recent guidelines focus on otoscopic examination, including moderate to severe bulging of the tympanic membrane with recent onset of ear pain or intense erythema of the tympanic membrane. In addition, the presence of a middle ear effusion is necessary to make the diagnosis. Management involves decreasing severity and duration of symptoms, including controlling pain and fever, improving hearing outcomes and preventing complications.  Recurrent acute otitis media is defined as at least three episodes in six months or four episodes in one year.  Tympanostomy tubes are typically placed for persistent middle ear effusion with associated hearing difficulties or for recurrent acute otitis media. The literature has focused on the use of tympanostomy tubes for middle ear effusion with conductive hearing loss, with little literature studying tube placement for recurrent acute otitis media. The current medical evidence suggests that providers should offer bilateral tympanostomy tube insertion to children with recurrent acute otitis media with unilateral or bilateral middle ear effusion at the time of assessment.  This patient has been diagnosed with recurrent otitis media with middle ear effusion noted at the time of evaluation for tympanostomy tube placement.  Therefore, the requested services are medically indicated for the treatment of this patient.  Final Result: The reviewer determined that the requested services are medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.  Credentials/Qualifications: The reviewer is board certified in pediatrics with sub-specialty certification in pediatric critical care 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 transcranial magnetic stimulation therapy for treatment of his major depressive disorder.  Findings:  The physician reviewer found that transcranial magnetic stimulation is a non-invasive brain stimulating procedure utilized in the treatment of major depressive disorder.  Transcranial magnetic stimulation tends to be very well-tolerated with fewer barriers than electroconvulsive therapy.  The American Psychiatric Association has endorsed transcranial magnetic stimulation for the acute phase treatment of major depressive disorder after failure of at least one antidepressant trial.  There sufficient evidence in the published, peer-reviewed medical literature to support the use of transcranial magnetic stimulation.  Transcranial magnetic stimulation represents a safe and appropriate clinical intervention for this case.  The treatment is consistent with good medical practice and is reasonably expected to improve the patients condition and prevent a more serious episode of illness.  All told, transcranial magnetic stimulation is medically indicated for the treatment of this patient.   Final Result: The reviewer determined that the services at issues were and 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 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.