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

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Flector patch 1.3%. Findings:  The physician reviewer found that Flector patch 1.3% is medically necessary for treatment of the patients medical condition. Haroutiunian and colleagues performed a systematic review to address and summarize the evidence of effectiveness and safety in topical non-steroidal anti-inflammatory medications (NSAIDs). The authors concluded that topical NSAIDs may vary significantly in their absorption kinetics and pharmacodynamic effects, based on their molecule and the formulation chosen. In acute and chronic low back pain, widespread musculoskeletal pain, and in peripheral neuropathic pain syndromes, current evidence supports the use of topical NSAIDs where oral alternatives are contraindicated. Flector patch 1.3% is equally effective and safe as an alternative to oral medications for treatment of patients with chronic pain and who have a contraindication to oral NSAIDs. Medical literature state that oral NSAIDs are contraindicated in patients who have gastrointestinal irritation due to an increased risk of gastric ulcers and gastric perforation. In this case, the patient is noted as having gastrointestinal irritation when using oral non-steroidal anti-inflammatory NSAIDs and would therefore benefit from using a topical medication. 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 anesthesiology with sub-specialty certification 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 breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. Patients who have dense breasts benefit most from breast tomosynthesis which has the ability to separate out the overlapping structures with the possibility of demonstrating an otherwise occult tumor. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. All told, the services at issue were 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 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:  Two physician reviewers found that breast tomosynthesis was likely to be more beneficial for this patient than any available standard modalities. Medical studies have shown that the addition of three dimensional (3D) digital breast tomosynthesis (DBT) reduces false positive results and increases cancer detection when compared to two dimensional full field digital mammography alone. Three dimensional DBT allows better characterization of possible masses, spiculation, and architectural distortion. In sum, there is sufficient evidence supporting the use of tomosynthesis for this patients routine breast cancer screening. 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.  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: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested advanced lipoprotein testing for evaluation of her medical condition.   Findings:  Three physician reviewers found that in this circumstance, prevention guidelines for the management of cardiac risk and dyslipidemia have been established. These guidelines 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, fibrinogen, genetic testing and homocysteine (Greenland, 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. Even though 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. For these reasons, advanced lipoprotein testing was not likely to be more beneficial for evaluation of the patients medical condition than any available standard modality.  Final Result: Three reviewers determined that the testing 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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary:   An enrollee has requested epidural steroid injections for treatment of his medical condition.  Findings:  The physician reviewer found that there is a lack of support for the services at issue in this clinical setting.  There is a lack of documentation of physical findings consistent with lumbar radiculopathy.  The records do not document motor or sensory loss or loss of reflexes.  Additionally, there is no nerve conduction velocity/electromyography (NCV/EMG) testing documented. Clinical practice guidelines suggest documenting these before embarking on any intervention.  There is also a lack of documentation of physical therapy or medication trials prior to these interventions.  A large controlled trial by Friedly and colleagues, in which both patients and clinicians were unaware of the treatment assignments, provides no evidence of a treatment effect at six weeks with fluoroscopically guided epidural injections of glucocorticoids plus lidocaine as compared with lidocaine alone.  In sum, epidural steroid injections were not medically necessary for the treatment of this patient.  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 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 residential treatment center services for treatment of his behavioral health condition.  Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue.  In this case, the patients alcohol use disorder was complicated by co-occurring mood and anxiety disorders.  This is of particular relevance since it has been well-established in both clinical practice and the medical literature that anxiety-ridden mood disorders, without the complication of addictive illness, are notoriously difficult to treat and in general have poorer outcomes.  The patients alcohol use dominated his daily routine, generated distress and caused significant impairment across multiple domains of functionality.  He had strained relationships and occupational problems due to his drinking.  In this clinical setting, limiting the number of days of residential treatment would have been inadequate in consolidating the issues that prompted admission or generating the therapeutic momentum necessary for the patient to succeed in a less restrictive treatment setting.  Based on the alcohol use history, social environment and psychiatric comorbidity, it is likely that the patient would have promptly relapsed and required re-admission if he was discharged prematurely.  Both the services and setting were safe, appropriate and consistent with good practice, while the duration of treatment aligned with community standards.  All told, the residential treatment center services at issue were medically indicated for the treatment of this patient.  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 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: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested general anesthesia for the enrollees dental procedure. Findings: The physician reviewer found that there is a lack of support for the requested services in this clinical setting. Dental literature describes the standard of care to utilize sedation in dentistry in the lowest level possible in the continuum of care. Per the guidelines, there is an increasing risk to the patient as the level of sedation progresses. The patient states he has PTSD and dental phobia. The patient feels he would not be a good candidate for full extraction under local anesthesia. However, the submitted documentation does not provide any history of failed attempts at dental care under lesser levels of sedation. As such, local anesthesia and conscious sedation, prior to authorizing general anesthesia, are shown to be reasonable and applicable. For these reasons, the requested general anesthesia is not shown to be medically necessary during the patients dental procedure.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: The reviewer is board certified in dentistry 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 the digital breast tomosynthesis for the evaluation of the enrollees medical condition. Findings:  The physician reviewers found that tomosynthesis often allows radiologists to separate dense glandular elements from underlying mass and architectural distortion resulting in a decrease in callbacks and increase in detection of small cancers. Final Result: Two of the three reviewers determined that the services at issue were likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned. Credentials/Qualifications: Physician reviewers number one, two, and three are board certified in diagnostic radiology and 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 authorization and coverage for Harvoni for 12 weeks for treatment of the enrollees hepatitis C.  Findings:  The physician reviewer found that according to the most recent joint guidelines issued by the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America, all patients with chronic hepatitis C should be treated except those with limited life expectancy due to non-liver-related conditions.  The guidelines recommend that all patients should be treated, regardless of fibrosis stage.  Per the guidelines, non-cirrhotic treatment-naive genotype 1a patients should be treated with Harvoni for 12 weeks.  These 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 1 regardless of fibrosis stage.  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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for lumbar sympathectomy for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that this patient has a severe form of plantar hyperhidrosis that has already resulted in falls.   It is refractory to conservative treatment strategies.  Per the medical records, this patient is well-informed of the risks of the planned lumbar sympathectomy procedure.  There are limited treatment options in this clinical setting.  Final Result: Two of the three reviewers determined that the requested services are 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: Physician reviewers number one, two, and three are board certified in surgery and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for autonomic testing for evaluation of the enrollees medical condition. Findings:  Two of the three reviewers found per the medical evidence, POTS is an indication for autonomic testing.  This patient also has Sjogrens syndrome which is also known to cause autonomic dysfunction.  Autonomic testing is necessary to understand the severity of the condition.  Understanding the severity of the condition would help determine the intensity of the supportive and medical therapy that would be required.  Final Result: The 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: Physician reviewers number one, two, and three 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.
Appeal type: Medical Necessity
Decision: Upheld Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for Repatha SureClick 140 mg/mL pen injector for treatment of the enrollees medical condition.  Findings:  The physician reviewer found that based on the records provided, the patient is with hyperlipidemia but no documented coronary disease and no documented familial hypercholesterolemia. Familial hypercholesterolemia usually manifests by a combination of physical exam findings and low-density lipoprotein cholesterol (LDL) levels that are at minimum above 180 mg/dl. None of the above is documented in the medical records provided for review. Repatha (evolocumab) is a PCSK9 inhibitor approved only for patients with heterozygous familial hypercholesterolemia or for patients with documented atherosclerotic heart disease who require additional lowering of LDL. In this case, the patient does not fit either of those criteria. In addition, PCSK9 inhibitors have not been studied in other patient populations such as this patient. Also current guidelines that are endorsed by several national organizations do not recommend the use of PCSK9 inhibitors in this primary prevention setting.  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 cardiovascular disease 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 reimbursement for excess skin removal surgery. Findings:  The physician reviewer found that The medical records note significant weight loss following bariatric surgery.  The patient is documented to have evidence of excess skin of the abdomen, breasts and buttocks.  However, the submitted photographs indicate that these conditions were mild.  Her functional problems included chronic rashes underneath skin folds and chronic neck pain.  With respect to conservative management of the rashes, she appears to have used a steroid cream and an antifungal agent.  Based on the entirety of the medical documentation and review of the photographs, the panniculectomy was medically necessary.  She had a lower abdominal pannus overhang.  She had chronic rashes that had failed reasonable conservative dermatologic treatment.  Although the degree of overhang is only mild based on the photographs, there are reports from multiple providers, including dermatology, that support her functional compromise and failed treatment.  This is not supported with the other areas of concern, including the breasts.  Based on the review of the photographs, the degree of ptosis and size of the breasts does not support that this is likely the source of her chronic neck pain.  There is some suggestion of a functional deficit related to chronic rashes underneath the breasts, but this has not been adequately detailed in the medical documentation provided, and the photographs do not support that this is likely as well. Based on the records provided, the patients condition does not constitute an abnormal structure of the body.  A review of the photographs depict relatively normal appearing structures of the breast, upper abdomen, thighs and buttocks/flanks.  There has not been adequate documentation that the planned procedures were provided to improve function.  The planned procedures would have created a possible cosmetic improvement. Final Result: The reviewer determined that a portion of the services at issue was 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 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.