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

Nature of Statutory Criteria/Case Summary: An enrollee has requested advanced lipoprotein for the enrollees medical condition. Findings: Three physician reviewers found that in this clinical setting, primary prevention guidelines for the management of cardiac risk and dyslipidemia have been established, are periodically updated by expert committees and are endorsed by several national organizations. These guidelines currently do not recommend routine performance of specialized tests in the context of assessing coronary risk including lipoprotein-associated phospholipase A2 (Lp-PLA2), sub-classifications of low-density lipoprotein (LDL), high-density lipoprotein (HDL) subclasses, lipoprotein(a), C-reactive protein (CRP), high sensitivity CRP, insulin, insulin resistance scoring, fibrinogen, genetic testing and homocysteine (Greenland, et al; Stone, et al). Treatment change or addition based on the results of screening with these specialized tests has not been shown to improve cardiac outcome incremental to that achievable by treatment based on standard risk factor profiling and basic lipid analysis. In addition, randomized trials evaluating treatment with therapy available to reduce homocysteine levels have not shown significant outcomes benefits (Lonne, et al; Toole, et al). Although results of some of these specialized tests may be abnormal and considered independent risk markers for coronary disease, there is a lack of controlled trials that demonstrate outcome benefits by treating routinely obtained abnormal results. Therefore, the advanced lipoprotein testing provided on has not been established 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 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 are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee has requested authorization and coverage for Harvoni 90-400 mg for 12 weeks for treatment of the enrollees chronic 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, regardless of fibrosis, should be treated except those with limited life expectancy due to non-liver-related comorbid conditions. Per the guidelines, Harvoni is a recommended regimen for certain hepatitis C genotypes, but not others.  The AASLD and IDSA guidelines cite data showing increased survival with earlier treatment. Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: The reviewer is board certified in 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for breast tomosynthesis for evaluation of the enrollees risk for breast cancer.   Findings:  The physician reviewer sfound that Tomosynthesis was approved by the U.S. Food and Drug Administration (FDA) for clinical use in 2011. 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 in 2014 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. Final Result: All 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: 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the anesthesia services administered during a colonoscopy for evaluation of the enrollees screening colonoscopy. Findings:  The physician reviewer found that this patient has an ASA preoperative physical status classification score of 1. Intravenous sedation performed by a non-anesthesiologist and non-certified registered nurse anesthetist is well supported in the peer-reviewed medical literature for this clinical setting. Further, the current medical research supports the use of intravenous sedation was appropriate for this patient given his low preoperative physical ASA status classification score.  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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for the following services: massage therapy as part of his physical therapy treatment plan; electrical stimulation as part of his physical therapy treatment plan; physical therapy once per week; and physical therapy performed by a physical therapist that physically assists with the assigned stretches and other exercises, as opposed to giving the enrollee a printout with instructions for home exercises for treatment of the enrollees dislocated right shoulder. Findings:  The physician reviewer found that the standard of care for a primary anterior dislocation is managed with acute reduction of the dislocation using one of many available techniques: A short period of immobilization, typically in internal rotation; and conservative non-surgical management of exercise and gradual return to activity. There is a lack of support in the medical literature as to the benefit of massage, electrical stimulation or long-term regular supervised physical therapy for the patients medical condition.  Exercises and activities can be gradually resumed with intermittent formal therapy assessments and basic exercises performed independently. Final Result: The reviewer determined that the requested services are not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.  Credentials/Qualifications: Physician reviewer number one 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for substance abuse residential treatment center (RTC) services for treatment of the enrollees chemical dependency. Findings:  The physician reviewer found that there is a lack of evidence that less restrictive treatment options during the episode of illness would have either been unsuccessful or would have been inappropriate. Although the RTC setting provides many advantages, the drug-free environment may not fully prepare the patient for exposure to and craving of the substance after discharge. Further, removing the patient from their family and community potentially undermines daily functioning. The American Psychiatric Association (APA) noted that, inpatient treatment should be used only when less intensive treatment has failed or is considered too risky. This patient was both psychiatrically and medically stable. The patient had stable vital signs and an unremarkable physical examination. The patient had not consumed opioids in five days and completed detoxification. The patient had a reassuring mental status examination with no acute psychiatric issues or safety concerns. The patient was motivated for treatment and he had strong family support. Considering the patients clinical presentation and treatment history, comprehensive specialty services provided at a lower level of care, such as partial hospitalization program (PHP) or intensive outpatient program (IOP) would have been reasonable and consistent with adequate care. 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 authorization and coverage for Norco 60 tablets per month for treatment of the enrollees chronic low back pain. Findings:  The physician reviewer found that not all non-opioid treatment options have been utilized for management of this patients pain. In addition, no mention of behavior therapy has been documented despite much research to support its use. The recent emergency room diagnosis of drug overdose and another recent occasion of the patient running out of Norco early support the need for services by a psychiatrist or addiction medicine for opioid medications. Moreover, pure mu agonists are not considered evidence-based treatments for fibromyalgia and may actually cause adverse effects in fibromyalgia patients.  Final Result: The reviewer determined that the requested medication is not medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be upheld.Credentials/Qualifications: The reviewer is board certified in 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested partial hospitalization program for treatment of the enrollees behavioral health condition.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the services at issue.  Discharge would have been premature, but the records do not support continued treatment at the partial hospital level of care. Considering the patients illness burden, anxiety and mood symptoms, a conservative treatment course was to be expected. The patient was anxious, overly-detailed and circumstantial. The treating provider increased her antidepressant medication. The patient endorsed somatic symptoms and skepticism regarding her ability to maintain a meal plan outside of a structured environment.  The patient needed encouragement and staff support to complete her midday meal.  The patient was noted as making progress, and her insight and judgment were improved as she entertained that some of her physical symptoms may be secondary to her anxiety.  The patients weight was up upon admission. The patient had no issues with eating her meals. The patient was motivated and more assertive. The patient was tolerating her medications well.  The patient was both psychiatrically and medically stable, and she was future oriented. Upon admission, this patients eating disorder necessitated comprehensive specialty care, and the partial hospitalization services were safe, appropriate and consistent with good medical practice.  However, based on the patients progress and clinical stability despite the chronicity of the illness, there was no evidence to suggest that partial hospitalization would further improve the patients condition and/or prevent a more serious episode of illness superiorly to well-coordinated services delivered in a less restrictive setting. In sum, the services at issue were medically necessary for treatment of this patient, but not thereafter.Final Result: The reviewer determined that the services at issue were medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be partially overturned.  Credentials/Qualifications: Physician 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested breast tomosynthesis for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the medical evidence supports the services at issue in this clinical setting.  Breast tomosynthesis provides advantages to radiologists interpreting mammograms.  This tomographic method often allows the reader to separate dense glandular elements from underlying mass/architectural distortion, resulting in a decrease in callbacks and increase in diagnostic accuracy and detection of small cancers compared to two-dimensional imaging alone.  Thus, the addition of breast tomosynthesis to the usual two-dimensional protocol was likely of greater benefit to the patient than had her examination been done with 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: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested Harvoni 90-400 mg for treatment of the enrollees chronic hepatitis C virus genotype 1a.  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, 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). Given this support, the requested 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 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 Harvoni for treatment of the enrollees hepatitis C virus. Findings: The physician reviewer found that the medical necessity of HCV eradication as per American Association for the Study of Liver Diseases/Infectious Diseases Society of America (AASLD/IDSA) recommendations exists irrespective of fibrosis score. AASLD/IDSA guidelines underscore this position with the following statement: Evidence clearly supports treatment in all HCV-infected persons, except those with limited life expectancy (less than 12 months). The records provided demonstrate that this patients life expectancy exceeds this limit. However, in this case, the provider requested a 12-week course of Harvoni.  In patients with viral loads less than 6 million IU/mL, an 8-week course of Harvoni is considered medically appropriate. Kowdley and colleagues state, `Ledipasvir-sofosbuvir for 8 weeks was associated with a high rate of sustained virologic response among previously untreated patients with HCV genotype 1 infection without cirrhosis. No additional benefit was associated with the inclusion of ribavirin in the regimen or with extension of the duration of treatment to 12 weeks.` This patient is treatment-naive without cirrhosis and according to the study performed by Kowdley and colleagues there is no additional benefit to an extended 12-week course of Harvoni in this clinical setting. Therefore, Harvoni for 12 weeks is not medically necessary for treatment of this patients HCV.  Final Result: The reviewer determined that the requested medication regimen 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 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary:  An enrollee requested positron emission tomography (PET) for evaluation of the enrollees medical condition.  Findings: Two physician reviewers found that the use of PET scans is becoming a standard of care in the behavioral neurology specialty. PET scans have been studied in the diagnosis of dementia for over 15 years. In a 2007 article, by Weaver and colleagues, they concluded that this technology has enough evidence to recommend it as an aid in the diagnosis of dementia. The most recent Cochrane meta-analysis of this subject suggests that this technology should not be routine, but that it has a role in cases without a clear diagnosis. In this case, the patient is observed to have a clinically significant cognitive disorder without a diagnosis. His findings could be related to severe depression mixed with attention deficit hyperactivity disorder, frontotemporal dementia, or atypical Alzheimers disease. Making an accurate diagnosis will allow the patient to plan his future, and assist his providers to develop a treatment plan. He underwent standard evaluation including EEG, MRI, and neuropsychological testing; but, no clear diagnosis is forthcoming.  In sum, the requested PET scan is likely to be superior over other alternatives for evaluating this patient.Final Result: Two 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 physician reviewers are board certified in neurology 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.