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

Nature of Statutory Criteria/Case Summary: An enrollee has requested gallium 68GA-dotatate positron emission tomography/computed tomography (DOTA-TOC PET/CT) scan for evaluation of the enrollees metastatic pancreatic neuroendocrine tumor.  Findings: The physician reviewer found that there is current data that gallium based scans such as the requested DOTA-TOC PET/CT are superior to conventional imaging including 18FDG-PET/CT in the evaluation of neuroendocrine tumors due to their molecular tagging. In several studies, the sensitivity and specificity of the gallium based scans have been remarkable. The challenge in this patients case, is the lack of appropriate serological markers, specifically Chromogranin and gastrin, which would be typically elevated in this type of tumor. The test requested is available at a limited number of facilities and ordinarily would not be medically necessary in the vast majority of patients. However, considering the unique circumstances of this case, the requested DOTA-TOC PET/CT is supported as medically necessary and appropriate for further evaluation and treatment of this patient.Final Result: The reviewer determined that requested diagnostic procedure is 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 Suboxone for treatment of the enrollees chronic back pain. Findings: The physician reviewer found that there is sufficient support for the requested medication in this clinical setting.  The use of buprenorphine (Suboxone) for management of chronic pain is supported by peer-reviewed literature (Roux et al; Malinoff et al).  In this patients case, he has been stable on the Suboxone dose and has an ongoing opiate maintenance agreement in place.  Although the patient is not in an ongoing psychological program, it is not consistent with good medical practice to discontinue Suboxone on that basis.  While psychological counseling has a place to support ongoing detoxification and maintenance, its role in ongoing pain management is not an absolute requirement.  This patient has been stable on his current medication regimen.  All told, Suboxone is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in anesthesiology with sub-specialty certification in pain medicine and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

An enrollee has requested reimbursement for three-dimensional breast tomosynthesis performed.  Findings:  The physician reviewers found that 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, increase in diagnostic accuracy and increase in 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 using two-dimensional imaging alone. Final Result: The reviewers determined that the service 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 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 continued inpatient psychiatric hospitalization for treatment of the enrollees behavioral health conditions. Findings:  The physician reviewer found that the submitted documentation fails to demonstrate the medical necessity of the services at issue.  The patient was not a danger to herself or to others.  She was not manic, and had no hallucinations in any modality.  She was not delusional or agitated.  The patient was psychiatrically stable on her medication regimen to the extent that she did not require inpatient level of care.  She was medication compliant.  She did not demonstrate patterns of instability in behavior or eating disorder behavior.  No new problems had arisen.  She participated in groups.  The daily physician progress notes were essentially the same each day.  There was no evidence to suggest that returning her to an environment of assisted living with intensive outpatient level of care would result in an exacerbation of her eating disorder behavior which would result in another inpatient hospitalization.  It should be noted that although she had a history of substance abuse, this issue was not addressed.  The current medical evidence does not support the services at issue in this clinical setting.  All told, continued inpatient psychiatric hospitalization was not medically indicated 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 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 reimbursement for the breast tomosynthesis performed for evaluation of the enrollees calcifications in the left breast. Findings: The three reviewers found that in this case, the initial breast tomosynthesis performed was warranted to better evaluate the area of developing pleomorphic calcifications. One of the primary arguments supporting the use of tomosynthesis is that it reduces the frequency of callbacks for further evaluation. On occasion, however, it is necessary to obtain further images, and it is not unusual to perform additional imaging. In this case, the initial screening mammogram included tomosynthesis. While the initial tomosynthesis was indicated and successful in detecting pleomorphic calcifications, the second tomosynthesis within such a short period of time was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the breast tomosynthesis performed was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: The reviewers determined that the diagnostic procedure at issue was not likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be upheld. Credentials/Qualifications: All three physician reviewers are board certified in 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 of Harvoni for treatment of the enrollees 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 should be treated except those with limited life expectancy due to nonliver-related conditions. This applies regardless of fibrosis stage or viral load, and advanced fibrosis is not required for treatment. Per the guidelines, treatment naive, genotype 1 patients should be treated with Harvoni. Patients with viral loads less than 6,000,000 IU/mL can be treated for eight weeks. These guideline recommendations are based on multiple randomized clinical trials. AASLD/IDSA guidelines cite data showing reduced survival with delayed treatment. For these reasons, the requested treatment with Harvoni 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 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: Findings:  Two physician reviewers found that Parkinsons disease is a chronic and progressive movement disorder that involves the malfunction of vital cells in the brain, specifically in an area known as the substantia nigra. These cells produce a chemical known as dopamine. As the disease progresses, the amount of dopamine produced decreases. In this case, the issue is whether the patient has Parkinsons disease. The patient has tremors, which are non-specific. In addition, he has gait abnormalities as well as depression and dizziness. At the time of the DaT-SPECT scan, the records indicate the patient did not have a diagnosis of Parkinsons disease. As noted in the current peer-reviewed medical literature, DaT-SPECT scans are most valuable when there are no absolute signs or symptoms suggestive for Parkinsons disease other than a tremor. Although a positive DaT-SPECT scan does not differentiate between the various parkinsonian syndromes, it is valuable in excluding a simple essential tremor which is more common given this patients age. Final Result: Two 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: 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 12 weeks of Harvoni 90-400 mg tablets 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.  The guidelines note that non-cirrhotic, treatment-naive, genotype 1 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.  The current guidelines cite data showing reduced survival with delayed treatment.  All told, the requested medication regimen of 12 weeks of Harvoni 90-400 mg tablets is medically indicated for the treatment of this patient.Final Result: The reviewer determined that the requested medication regimen is medically necessary for treatment of the patients medical condition. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: The reviewer is board certified in internal medicine with sub-specialty certification in gastroenterology and is actively practicing. The reviewer is an expert in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Medical Necessity
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for inpatient level of care for treatment of the enrollees behavioral health condition. Findings:  The physician reviewer found that the submitted documentation supports the medical necessity of the services at issue. The services provided could not have reasonably been delivered effectively at a less restrictive setting. Outpatient treatment would have resulted in inadequate care.  Premature discharge of individuals with severe mental illness and prominent psychosis increases patient morbidity and the likelihood of prompt re-admission. The patient had a serious underlying formal thought disorder as evidenced in part by his multiple hospitalizations and previous treatment with clozapine, which is an antipsychotic typically reserved for the most challenging cases. Although the patient showed some signs of improvement, he remained psychotic and gravely disabled per the attending provider.  A conference call to discuss the conservatorship was arranged for the following day, at which time he remained gravely disabled due to his psychiatric illness.  The patient had a significant medication change with the addition of Depakote and the discontinuation of lithium. Thereafter, the patient continued to display delusional thinking, thought blocking, poor insight and an inability to care for himself due to his psychiatric illness. He remained engaged in active treatment, while the providers worked with the patient and the patients parent for treatment planning purposes.  Considering the severity of his illness burden, retaining this patient in the inpatient setting until conservatorship disposition and formalization of aftercare was medically indicated.  Further, during the disputed timeframe, the acute inpatient setting remained safe, clinically appropriate, and consistent with standard medical practice. As such, it was medically reasonably for the patient to remain at inpatient treatment center to both improve the patients condition and to prevent a more serious episode of illness. 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: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested fentanyl citrate OTFC and methadone HCl tablets for the treatment of the enrollees chronic pain.  Findings: The physician reviewer found that the submitted documentation supports the medical necessity of a portion of the medications at issue.  The use of methadone for chronic pain is a well-established therapy.  Based on the medical records, the dose in this patients case is medically reasonable and necessary.  However, the use of immediate-release fentanyl is subject to U.S. Food and Drug Administration (FDA) mandated Risk Evaluation and Mitigation Strategy (REMS) program, and the use of fentanyl citrate OTFC for back pain is an off-label use.  The use of fentanyl citrate OTFC is restricted to cancer breakthrough pain.  All told, methadone HCl tablets were and are medically indicated for the treatment of this patient.  However, fentanyl citrate OTFC was not and is not medically indicated for the treatment of this patient.Final Result: The reviewer determined that a portion of the medications at issue was and is 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 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 computed tomography angiography (CTA) for evaluation of the enrollees end stage liver cirrhosis awaiting liver transplant.  Findings: The physician reviewer found that the requested diagnostic procedure has been established as medically necessary for evaluation of the patients medical condition. CTA of the chest is a radiologic examination of the structures in the chest that allows the clinician to see highly detailed vascular anatomy. The American College of Cardiology (ACC) recommends coronary angiography prior to liver transplantation when the patient has greater than two risk factors due to increased risk of poor outcomes in the transplanted patient with significant coronary artery disease (Raval, et al). The American Association for the Study of Liver Diseases (AASLD) recommends an evaluation of the coronary arteries in patients with diabetes (Murray, et al). In a head to head study, CTA was found to be equally effective as cardiac catheterization in revealing significant coronary artery disease (Moscariello, et al). In this case, an escalating pattern of liver disease manifesting as frequent admissions for liver failure related encephalopathy underscore the need for transplant evaluation. The presence of more than two cardiac risk factors including diabetes, hypertension and kidney disease is an indication of a high risk for coronary artery disease. In this clinical setting, the ACC guidelines support evaluation of coronary anatomy prior to transplantation. In addition, CTA is a reasonable alternative to cardiac catheterization in select patients such as those at higher risk for bleeding complications secondary to invasive catheterization. A patient with low platelet counts and liver failure related coagulopathy is at higher risk for bleeding complications. Therefore, CTA of the chest with and without contrast (CPT 71275) has been established as medically necessary for evaluation of the patients medical condition.Final Result: The reviewer determined that the requested diagnostic procedure is 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 anesthesiology with sub-specialty certification in 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: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested reimbursement for the digital breast tomosynthesis. Findings:  Two physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has heterogeneously dense breasts. It is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Final Result: Two 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: All three physician reviewers are board certified in diagnostic radiology and are actively practicing. The reviewers are experts in the treatment of the enrollees medical condition and knowledgeable about the proposed treatment through recent or current actual clinical experience treating those with the same or a similar medical condition.
Appeal type: Experimental/Investigational
Decision: Overturned Decision of Health Plan

Nature of Statutory Criteria/Case Summary: An enrollee has requested digital breast tomosynthesis for evaluation of the enrollees breast cancer screening. Findings: Three physician reviewers found that tomosynthesis is a technique that was developed as a problem solving adjunct to routine mammography. In this case, the patient has breasts that have been described as heterogeneously dense.  In addition, there have been prior masses that have been felt to be benign. Tomosynthesis is a valuable tool in better characterizing masses. While one could make the argument that her mammogram has not changed since the last study, it is specifically those patients who have dense breasts that can benefit most from tomosynthesis. The ability to separate out the overlapping structures enables the possibility of demonstrating an otherwise occult tumor. Accordingly, the breast tomosynthesis was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy.Final Result: Three reviewers determined that the diagnostic procedure at issue was likely to be more beneficial for evaluation of the patients medical condition than any available standard therapy. Therefore, the Health Plans denial should be overturned.Credentials/Qualifications: All three physician reviewers are board certified in diagnostic radiology 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.